Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
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Common Bile Duct.......................................49
Pancreas.........................................................49
Spleen............................................................50
Suprarenal Glands.........................................51
Kidneys: Relations........................................52
Ureter.............................................................52
Inferior Vena Cava........................................54
Lumbar Sympathetic Trunks.........................54
Pelvis............................................................................................................................56
Pelvic Brim....................................................56
Pelvic Diaphragm..........................................56
Superficial Perineal Pouch............................57
Deep Perineal Pouch.....................................58
Ischiorectal Fossa..........................................59
Peritoneum in Female Pelvis.........................59
Broad Ligaments (of the Uterus)...................60
Rectum..........................................................60
Anal Canal.....................................................61
Urinary Bladder.............................................62
Prostate Gland...............................................63
Seminal Vesicles...........................................64
Ovary.............................................................64
Uterus............................................................65
Supports of the Uterus...................................66
Uterine (Fallopian) Tubes.............................67
Vagina...........................................................69
Ductus (Vas) Deferens..................................70
Male Urethra.................................................71
Pudendal Nerve.............................................72
Lumbar Plexus..............................................72
Lower Limb................................................................................................................74
Venous Drainage of Lower Limb.................74
Lymphatic Drainage......................................76
Hip Joint........................................................78
Knee Joint......................................................79
Ankle Joint....................................................82
Femoral Triangle...........................................83
Popliteal Fossa..............................................83
Femoral Artery..............................................84
Sciatic Nerve.................................................85
Tibial Nerve..................................................85
Common Peroneal Nerve..............................86
Popliteal Artery.............................................87
Femoral Nerve...............................................88
Arches of Foot (Medial & Lateral Longitudinal)................................................................................89
Gluteal Muscles.............................................89
Cutaneous Innervation of Lower Limb.........90
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Upper Limb
Female Mammary Gland
Description
• Hemispherical in shape
• Modified form of sweat gland (Sebaceous glands)
• Derived from epithelium of skin
Position
• Overlies pect. major, serratus ant. & ext oblique muscles
• Extends: vertically from 2nd to 6th rib
Horizontally from lat. margin of sternum to midaxillary line
• Greater part embedded in superficial fascia
• A small part (axillary-tail) pierces deep fascia at lower border of pect. major and enters axilla
• Seperated from deep fascia by retromammary space (area of loose CT)
• Nipple often at 4th intercostal space, surrounded by area of pigmented skin (areola)
Inter Organization
• Consists of 15-20 lobes radiating outwards from nipple
• Lobes further separate by fibrous septa extending from skin to deep fascia = ligaments of Cooper
• Main duct of each lobe opens separately onto nipple
• They possess a dilated ampulla just before termination
Arterial Supply
• Superior thoracic artery
• Lateral thoracic artery
• Internal thoracic artery
• Posterior intercostal arteries
Venous Drainage
• Axillary vein
• Internal and lateral thoracic veins
• Intercostal veins
Nerve Supply
• 2nd to 6th intercostal n.
• Supraclavicular n. from cervical plexus
Lymphatic Drainage
3 communicating plexuses:
1. Cutaneous (subareolar)
2. Periglandular
3. in deep fascia = not impt
• The remaining lymph follow branches of internal thoracic artery parasternal nodes
• Some will also drain into posterior intercostal nodes
• Sometimes deep drainage occurs via interpectoral (Rotters) nodes
Clinical Notes
Carcinoma of breasts: Cancer cells follow lymph streams to axillary lymph nodes
produce nests of tumour cells called metastasis
Symptoms 1. Enlargement of lymph nodes
2. Dimpling of skin
3. Retraction of nipple
60% of carcinoma: upper lateral quadrant
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The Axilla and Contents
The axilla = Pyramidal space between root of arm and chest wall
= Impt passage for nerves, blood vessels and lymphatics from neck to upper limb.
Boundaries
Base 1. Axillary fascia
2. Bounded: Anteriorly by anterior axillary fold (pect. major)
Posteriorly by posterior axillary fold (lats dorsi)
Medially by chest wall
Contents
1. Axillary artery and branches
2. Axillary vein and tributaries
3. Brachial plexus (cords and branches)
4. Axillary lymph nodes and vessels
5. Lat. cutaneous branches of intercostal nerves
6. Long thoracic nerve
7. Intercostobrachial nerve
Brachial Plexus
1. situated partly in neck & partly in axilla
2. formed by union of ventral rami of C5-T1 spinal nerves
Components
Root - ventral rami of C5 to T1
- If C4-T1 prefixed
- If C5-T1 postfixed
Trunks Upper = C5 + C6
Middle = C7
Lower = C8 + T1
Divisions Each trunk divides into ant & post divisions
Cords Lat cord = ant division of upper trunk + ant division of middle trunk ie. C5, 6
+7
Med cord = ant division of lower trunk
ie. C8 + T1
Post cord = post divisions of all 3 trunks
ie. C5. C6. C7, C8 +T1
Note: Roots & trunks found in neck
Division found behind clavicle
Cords & branches found in axilla
Branches
Roots 1. dorsal scapular n C5
2. long thoracic n C5, C6 + C7
Upper Trunk 1. suprascapular n C5, C6
2. n to subclavius C5, C6
Lat cord 1. musculocutaneous n
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(C5, C6 & C7) 2. lat root of median n
3. lat pectoral n
Med cord 1. ulnar n
(C8 + T1) 2. median root of median n
3. med cutaneous n of arm
4. med cutaneous n of forearm
5. med pectoral n
Post cord 1. radial n C5 to T1
2. axillary n C5 + C6
3. upper & lower subscapular n C5 + C6
4. thoracodorsal n C6, C7 + C8
Axillary Artery
Origin
• Continuation of the subclavian artery
• at lat. border of 1st rib, at apex of axilla
Termination
• At lower border of teres major at base of axilla
• continues as brachial artery
Course
• divided into 3 parts by pect. major
1st part From lat border of 1st rib to upper border of pect. major
2nd part Behind pect. major
3rd part From lower border of pect.major
to lower border of teres major
Relations
Ant Post Lat Med
1st 1. pect. major 1. med cord of brachial All 3 cords of Axillary vein
Part 2. subclavius plexus brachial plexus
3. clavipect fascia and skin 2. long thoracic n
4. cephalic vein 3. med pect n
4. 1st i/c space
5. 1st digitation of serratus
ant.
2nd 1. pect major 1. post cord of brachial Lat. cord of brachial 1. med. cord of brachial
Part 2. pect minor plexus plexus plexus
3. clavipect fascia and skin 2. subscapularis 2. med pect. n
3. axillary vein
3rd 1. upper: pect major 1. subscapularis 1. coraco-brachialis 1. axillary vein
Part lower: subcut tissue 2. lat dorsi 2. biceps 2. ulnar n.
2. med root of median n. 3. teres major 3. humerus 3. med cut n of forearm &
4. axillary n. 4. musculocut n arm
5. radial n. 5. median n
Branches
1st Part: 1. Highest thoracic artery
2nd Part: 1. Thoracoacromial artery
2. Lat. thoracic artery
3rd Part: 1. Subscapular artery
2. Ant. circumflex humeral artery
3. Post circumflex humeral artery
Surface Marking
1. Abduct arm, supinate hand
2. Pt 1: middle of clavicle
Pt 2: mid-part of epicondyles, 1 inch up
3. Draw line joining the 2 pts
The artery is the upper 1/3 of the line
Clinical Notes
The artery can be compressed (only 3rd part) to stop
1. Severe bleeding
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2. Swelling of artery
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Cubital Fossa
Triangular intramuscular space on ant. surface of elbow
Boundaries
Base Imaginary line between the 2 epicondyles of humerus
Apex Crossing of pronator teres and brachioradialis
Lat Brachioradialis
Med Pronator teres
Floor Lat: Supinator
Med: Brachialis
Roof Skin and fascia, bicipital aponeurosis
Clinical Notes
Venipuncture: For withdrawal of blood sample / transfusion
For intravenous feeding / anaesthetics
Sites of venipuncture is usually median cubital vein because:
1. Overlies bicipital aponeurosis deep structure protected
2. Not accompanied by nerves
Brachial Artery
Origin
• Continuation of axillary artery
• At lower border of teres major
Termination
• At cubital fossa at level of neck of radius
• Bifurcates into ulnar and radial arteries
Course
• Lies on med. side of humerus in proximal 1/3 of its course
• Lies directly in front of humerus in distal 1/2 of its course
• Passes deep to bicipital aponeurosis and into cubital fossa
• Accompanied by 2 vena comitantes
Relations
Ant Overlapped on lat side by biceps & coracobrachialis
Upper part: med cut n. of forearm
Lower part: bicipital aponeurosis & median cubital vein
Post 1. Triceps
2. Insertion of coracobrachialis and brachialis
3. Radial n
4. Profundus brachii artery
Lat Upper part: 1. Median n.
2. Biceps and coracobrachialis
Lower part: 1. Tendon of biceps
Med Upper part: 1. Ulnar n.
2. Basilic vein
Lower part: 1. Median n.
Branches
1. Profundus brachii artery accompany radial n into post compartment
2. Nutrient artery to humerus
3. Muscular branches biceps
4. Sup. and inf. ulnar collat. arteries
Surface Markings
1. Abduct arm, supinate hand
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2. Pt 1: middle of clavicle
Pt 2: mid-pt of epicondyles, 1 inch up
3. Connect the 2 points
The lower 2/3 of this line marks the brachial artery
Clinical Notes
1. The artery can be compressed to control hemorrhage due to injuries of forearm
2. Taking of blood pressure using sphygmometer
Scapular Anastomosis
Functions
• To compensate for ligation / obstruction of the main artery
• Arteries above the stoppage will anastomose with those
below the stoppage of the main trunk
to ensure an adequate supply of blood to tissues
• In this case, the main artery concerned = axillary artery
Arteries Involved
Branches of Subclavian Artery 1. suprascapular artery
2. desc branch of supf cervical art
3. desc scapular art = dorsal scapular art
Branches from Axillary Artery 1. subscapular art
2. circumflex scapular branch of subscapular art
3. ant circumflex humeral art
4. post circumflex humeral art
Sites of Anastomosis
Sites Arteries involved
Infraspinous fossa Btw suprascapular & circumflex scapular
Med border of scapula Btw dorsal scapular & circumflex scapula
Surgical neck of humerus Btw ant & post humeral circumflex
Thoracic walls Btw pect branches, intercostals, lat thoracic & thoracodorsal
Acromion Btw acromial & post circumflex humeral
Clinical Notes
Ligature of 1st part of axillary artery or 3rd part of subclavian artery
blood will flow via the scapular anastomosis
Scapular Movement
• Little, if any, movements occur at shoulder joint
without accompanying movement / displacement of rest of shoulder girdle, esp scapula
• This is best illustrated by abduction of arm
in a coronal plane of a vertical position
Role of Clavicle
• movements of scapular rotation:
40° = clavicular elevation & rotation
20° = scapular rotation at a/c joint
• clavicle rotates on its long axis with fulcrum at coracoacromial lig
• scapula rotates at a/c jt
therefore, angle btw clavicle & scapula changes constantly
• clavicle also serves as a strut to keep the acromion from chest wall
General Notes
• duing abduction in coronal plane,
humerus is lat rotated to prevent greater tubercle hitting the acromion.
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• scapular rotation occurs together with abduction,
but to a lesser extent than the humerus
• Note that the 1st 120° is the angle made by humerus
wrt to scapula & not wrt the body
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Shoulder Joint
Type
synovial ball & socket joint
Articulation
• spherical head of humerus
• glenoid cavity of scapula, which is deepened by ring of fibrous cartilage
= glenoid labrum
• articular surfaces covered with hyaline cartilage
Capsule
• fibrous capsule, thin & loose
• strengthened by tendinous slips of rotator cuff
• Attachments: superiorly = root of coracoid process
laterally = anat neck of humerus
medially = glenoid cavity beyond glenoid labrum
Ligaments
glenohumeral lig • 3 weak bands
• from supraglenoid tubercle of scapula to lesser tubercle & anat head of humerus
trnvs humeral lig from greater to lesser tubercle of humerus
coracohumeral lig from lat side of base of coracoid process to anat neck of humerus
coracoacromial lig lat border of coracoid process to acromion
Synovial Membrane
• lines fibrous capsule
• tubular sheath for tendon of long head of biceps in bicipital groove
• reflected onto glenoid labrum & neck of humerus to articular margin of head
Related Bursae
1. subscapular bursa
2. subacromial bursa
Intracapsular Structures
long head of biceps tendon: intracapsular & extrasynovial
Nerve Supply
1. axillary n
2. suprascapula n
3. lat pect n
Blood Supply
1. ant & post circumflex humeral art
2. subscapular art
3. suprascapular art
Movements
Flexion Extension Abduction Adduction Med Rotation Lat Rotation
deltoid (ant fibres) deltoid (post fibres) deltoid (middle fibres) pect major subscapularis infraspinatus
pect major lat dorsi supraspinatus lat dorsi lat dorsi teres minor
biceps teres major teres major teres major deltoid (post fibres)
coracobrachialis
Circumduction = combination of the above movements
Relations
Anteriorly Posteriorly Superiorly Inferiorly
1.subscapularis 1. infraspinatus 1. supraspinatus 1. long head of triceps
2.axillary vsls 2. teres minor 2. deltoid 2. axillary n
3.brachial plexus 3. subacromial bursa 3. post circumflex humeral vsls
4. coracoacromial lig
Stability
• Free Movement, shallow glenoid cavity, loose fibrous capsule
unstable
• Stability due to rotator cuff : Subscapularis
: Supraspinatus
: Infraspinatus
: Teres minor
• Inferior part not supported weakest part
Clinical Notes
1. Dislocation : Axillary n, which crosses surgical neck of humerus may be
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damaged deltoid paralysed
: injury to brachial plexus
2. Rupture of rotator cuff
Musculocutaneous Nerve
Origin
• Lat cord of brachial plexus
• C5, 6, 7
Course
• Starts at distal border of pect. minor
lies above and lat. to 3rd part of axillary artery
• Runs downwards and lat.
• Pierces coracobrachialis
• Descends between biceps and brachialis
• In cubital fossa, lies lat. to tendon of biceps
• Pierces deep fascia passes deep to cephalic vein
• Continues as lat. cutaneous n of forearm
Branches
Bracnhes Supplies
Muscular 1. biceps
2. brachialis
3. coracobrachialis
Articular to elbow joint
Lat. cutaneous n of forearm ant, lat. aspects of forearm
Surface Marking
Part 1 : Tip of coracoid process
Part 2 : Lat border of biceps tendon in cubital fossa
Join the 2 parts together with the arm abducted and supinated
Clinical Notes
Injury results : Severe weakness of flexion of elbow
: Loss of sensation over lat. aspect of forearm
Axillary Nerve
Origin
• Smaller terminal branch of post cord of brachial plexus
Course
• Run along post. wall of axilla above radial n. and behind axillary artery
• Enters quadrilateral space along with post. circumflex humeral artery
• Winds round med and post aspects of surgical neck of humerus
inf to capsule of shoulder joint
• Divides into ant and post terminal branches
Branches
Branch Supplies
Articular branch shoulder joint
Ant. terminal branch • Winds round surgical neck of humerus
• Supplies deltoids and skin covering its lower part
Post terminal branch • Supplies teres minor and deltoids
• Emerges from post border of deltoids as upper lat
cutaneous n of arm
Clinical Notes
Injury in Axilla due to
1. Pressure of crutch in armpit
2. Downward displacement of humeral head
3. May also be injured by fracture of surgical neck of humerus
Effects
1. Paralysis of deltoids : Wastes rapidly
: Impairment of abduction of shoulder joint
Notes: Deltoids also perform flexion and extension of joint. Its loss here not felt due to presence of other strong
muscles
2. Paralysis of teres minor: Not recognizable clinically
3. Loss of skin sensation over lower part of deltoids
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Elbow Joints
Type
Synovial hinge joint
Articulation
Humerus Trochlea
Capitulum
Ulna Trochlear notch
Radius Head
Capsule
• Fibrous capsule
• Attachments of capsule
Anteriorly Posteriorly
• Coronoid and radial fossae of humerus • Margin of olecranon fossa of humerus
• Front of med. and lat. epicondyles • Upper margin and sides of olecranon process of
• Margin of coronoid process of ulna and annular lig ulna
around head of radius • Annunlar lig
Note: Not directly attached to radius
Ligaments
Lat Lig • From lat epicondyle of humerus below common extensor origin to upper margin of annular lig
Med. Lig • Ant band: med. epicondyle coronoid process
• Post band: med. epicondyle med. side of olecranon
• Transverse band: between ulnar attachment of ant. and post. bands
Note: Lodges ulnar n to med epicondyle
Annular Lig • Attached to margins of radial notch of ulna
• Holds head and neck of radius in sup. radioulnar joint
Synovial Membrane
• Lines capsule and fossae of humerus
• attached to articular margins of all 3 bones, continues with memb. of sup. radioulnar joint
Related Bursae
1. Subcutaneous olecranon
2. Subtendinous olecranon bursae
Nerve Supply
1. Musculocutaneous n
2. Median n
3. Ulnar n
4. Radial n
Blood Supply
Elbow joint anastomosis
1. Brachial a
2. Profunda brachii a
3. Radial and ulanr cell. a
4. Post. interosseous a
Movements
Flexion 1. Brachialis
2. Biceps
3. Brachioradialis
limited by contact of ant surfaces of arm and forearm
Extension 1. Triceps
2. Anconeus (stabilizes joints)
limited by tension of ant lig and brachialis muscle
Carrying Angle
• When arm is fully extended and supinated, angle between extended ulna and humerus ∼ 170°
• This enables extended forearm to clear side of hip in swinging movements of upper limb and when carrying heavy loads
Note: Carrying angle greater in women than in men
Relations
Anteriorly 1. Brachialis
2. Tendon of biceps
3. Median n
4. Brachial artery
Posteriorly Triceps
Medially 1. Ulnar n
2. Common flexor origin
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3. Pronator teres
Laterally 1. Common extensor origin
2. Supinator
3. Anconeus and n to anconeus
Clinical Notes
• Stability due to: 1. Shape of bones ie wrench shape of articular surface
of olecranon and pulley shape of trochlear
2. Strong med. and lat. lig
• Ant and post aspects of capsule weak
• Posterior dislocation - Normally, the 2 epicondyles and top of olecranon in an extended forearm are in
straight line flexion form aspect of equilateral triangle
This is not so in a dislocation
• Ulnar n lies bhd med. epicondyles
Post. dislocation may lead to lesion of ulanr n ulnar n palsy
Flexor and Extensor Retinacula
Flexor Retinaculum
• Thickening of deep fascia across front of wrist, size of 10 cent stamp
• Covers concave ant. surface of carpus carpal tunnel
• Passage of median n and flexor tendons
Attachment
Medially Laterally Upper border Lower border
Pisiform bone, hook of Tubercle of scapholid, Continuous with deep fascia Continuous with aponeurosis
hamate trapezium of forearm
Related Structures
Sructures above Retinaculum (M L) Structures below retinaculum (M L)
1. Flexor carpi ulnaris tendon 1. Flexor digitorum superficialis tendon (Bhd: profundus
2. Ulnar n tendon)
3. Ulnar artery 2. Median n
4. Palmar cutaneous brach of ulnar n 3. Flexor pollicis longus tendon
5. Palmaris longus tendon 4. Flexor carpi radialis tendon
6. Palmar cutaneous branch of median n
7. Palmar branch (ie superficial branch) of radial artery
Clinical Notes
1. The flexor retinaculum holds down the flexor tendons prevent bawing effect
2. Ulnar n, superficial may be injured
3. Carpal Tunnel Syndrome
• Compression of median n in carpal tunnel
• Due to changes in synovial sheaths of flexor tendons (which become thicker) or arthritic changes in carpal bones
• Symptoms : pins and needles along lat 3 1/2 fingers
: Weakness of thenar muscles
• Treatment : Longitudinal incision thru flexor retinaculum
Extensor Retinaculum
• thickening of deep fascia across back of wrist
• covers groove on post surface of ulna & radius
6 tunnels
• tunnels lined with synovial sheath, separated by fibrous septa
• passage of extensor tendons
Attachments
medially pisiform bone
hook of hamate
laterally distal end of radius
upper border continuous with deep fascia of forearm
lower border continuous with deep fascia of hand
Related Structures
Structures Above Retinaculum (M L) Structures Below Retinaculum
1. dorsal (post) cut branch of ulnar n 6 tunnels
2. basilic vein 1. extensor carpi ulnaris tendon
3. cephalic vein 2. extensor digiti minimi
4. superficial branch of radial n 3. extensor digitorum
extensor indicis (behind)
(& with ant inter art & post int n)
4. extensor pollicis longus tendon
5. extensor carpi radialis longus & brevis tendons
6. abductor pollicis longus & extensor pollicis brevis
tendon
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Radiocarpal / Wrist Joint
Type
• synovial ellipsoid jt
Articulation
Proximally 1. carpal surface of radius
2. articular disc
Distally scaphoid, lunate & triquetral
Capsule
• encloses jt
• Attachment
superiorly lower ends of radius & ulnar
inferiorly proximal row of carpal bones
Ligaments
Anteriorly palmar radiocarpal lig
palmar ulnocarpal lig
Posteriorly dorsal radiocarpal lig
Laterally radial collat lig (lat lig)
styloid process of radius to scaphoid
Medially ulnar collat lig (med lig)
styloid process of ulnar to triquetral
Synovial Membrane
• Lines capsule
• attached to articular margins
Nerve Supply
1. Ant. and post. interosseous n.
2. Median and ulnar n.
Blood Supply
Ant and post carpal rete
Movements
Flexion Flexor carpi ulnaris
Flexor carpi radialis
Palmaris longus
Flexor digitorum supf & profundus
Extension Extension carpi ulnaris
Extensor carpi radialis longus & brevis
Extensor digitorum
Abduction Flexor carpi radialis
Extensor carpi radialis longus & brevis
Adduction Flexor carpi ulnaris
Extensor carpi ulnaris
Relations
Anteriorly Tendons of flexor muscles
Posteriorly Tendons of extensor muscles
Laterally Radial artery
Medially Post cutaneous branch of ulnar n.
Clinical Notes
Colle’s fracture : Fracture of distal end of radius
: Results of fall on outstretched hand with forearm pronated
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Ulnar Artery
Origin
• Terminal branch of brachial artery
• Arises in cubital fossa at level of neck of radius
Course
Forearm • Travels along ulnar side of forearm
• At wrist superficial
• Lies between tendons of flexor carpi ulnaris and flexor dig supf
• Enters palm supf to flexor retinaculum
and lat to pisiform bone and ulnar n
Hand • Enters palm supf to flexor retinaculum
lat to pisiform bone & ulnar n
• Gives off deep branch
(which joins radial artery deep palmar arch
• Continues as supf palmar arch
Superficial Palmar • Formed by ulnar art (med.)
Arch and supf palmar branch of radial artery (lat.)
• Deep to palmar aponeurosis
supf to long flexor tendons
• Max. convexity at distal border of fully extended thumb
• 4 digital arteries arise
Relation
Anteriorly 1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor digitorum superficialis
5. Flexor carpi ulnaris
Posteriorly Upper part: Brachialis
Lower part: Flexor digitorum profundus
Laterally Upper part:
Lower part: Flexor digitorum superficialis
Medially Upper part:
Lower part: Ulnar n
Clinical Notes
1. Supf postion easily damaged in lacerations of wrist
2. May be palpated as it crosses supf to flexor retinaculum
Radial Artery
Origin
• Terminal branch of brachial artery
• Arises in cubital fossa at level of neck of radius
Course
Forearm • Travels along radial side of forearm
• Upper part is deep to brachioradialis
Lower part is subcutaneous
• Reaches styloid process of radius and
winds around lat aspect of wrist to reach dorsum of hand
Dorsum of hand • Pass beneath tendons of abductor pollicis longus
and extensor pollicis longus and brevis
• Give off : dorsal carpal branch
: dorsal digital arteries
• Reach interval between 2 heads of 1st interosseous muscle at dorsum of hand
Palm • Enters palm between 2 heads of 1st interosseous muscle
• Gives off : 1. Princeps pollicis
: 2. Radialis indicis arteries
• Curves medially between 2 heads of adductor pollicis
• Lies deep to long flexor tendons
on bases of m/c bones and interossei
• Joins deep branch of ulnar artery deep palmar arch
Deep Palmar Arch • Max. convexity at proximal border of fully extended thumb
• Gives off : Palmar m/c arteries which join digital
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branches of supf palmar arch
: Braches to wrist joint anastomosis
Relations
Anteriorly Upper part: Brachioradialis
Lower part: Skin and fascia
Posteriorly 1. Tendon of biceps
2. Supinator
3. Insertion of pronator teres
4. Radial head of flexor digitorum superficialis
5. Flexor pollicis longus
6. Pronator quadratus
7. Distal end of radius
Laterally 1. Brachioradialis
2. Radial n. (middle part)
Medially Upper part: Pronator teres
Lower part: Flexor carpi radialis
Clinical Notes
Can be palpated in “anatomical snuffbox”
Anatomical snuffbox
Med extensor pollicis longus
Lat 1. abductor pollicis longus
2. extensor pollicis brevis
Median Nerve
Origin
• From med and lat cords of brachial plexus in axilla
• C5, 6, 7, C8, T1
Course
Arm • Upper 1/2 of arm: Runs lat to brachial artery
• At level of insertion of coracobrachialis:
- crosses supf to brachial art and
- continues on med side, reaches cubital fossa
Forearm • Leaves cubital fossa
passes between the 2 heads of pronator teres
• Separate from ulnar artery by deep head of pronator teres
• Passes btw flexor dig supf & flexor dig profundus
neurovascular plane
• At wrist, emerges from lat border of flexor dig supf
becomes supf
• Lies btw tendons of flexor carpi radialis & palmaris longus
• Enters palm by passing bhd flexor retinaculum
Hand • Divides into lat and med branches
• Lat. branch : supplies thenar muscles
• Med branch : supplies lat 3 1/2 digits, including distal portion of
the dorsum of these digits
: supplies 1st 2 lumbricals
Branches
Arm 1. Twig to brachial artery
2. Articular to elbow joint
Forearm
1. Muscular 1. Pronator teres
2. Flexor carpi radialis
3. Palmaris longus
4. Flexor digitorum superficialis
17
4. Palmar cutaneous branch supplies skin over lat. part of palm
Note: In forearm: supplies all flexors except med 1/2 of flexor dig profundus
and flexor carpi ulnaris
In hand: supplies thenar muscles, 1st 2 lumbricals and lat 3 1/2 fingers
Surface Markings
In arm: Pt 1: Distal end of axillary artery
Pt 2: Middle of cubital fossa
Join 2 points together
In forearm: Continue this line to middle of front of wrist
Clinical Notes
1. Carpal Tunnel Syndrome
- Compression of median n. by flexor tendon sheath in carpal tunnel
- Symptoms: 1. Pins and needles in lat. 3 1/2 fingers
2. Weakness of thenar muscles
2. Lesion of n. at elbow or wrist
Course
Axilla • lies btw axillary artery & vein
• lies deep to med cutaneous n. of forearm
Arm • upper 1/2 of arm: runs on med. side of brachial artery
• at insertion of coracobrachialis: pierces med. intermuscular septum
& enter post compartment
• accompanied by sup ulnar coll. artery
• in post. compartment : runs in front of med. head of triceps
: passes bhd med. epicondyle – enters forearm
Forearm • enters forearm btw the 2 heads of flexor carpi ulnaris
• lies on flexor dig profundus (& below flexor carpi ulnaris)
• accompanied by ulnar artery on lat. side in distal 2/3 of arm
• at wrist – becomes supf
• lies btw tendons of flexor carpi ulnaris & flexor dig supf
• enters hand (palm) superficial to flexor retinaculum
along with ulnar art (which is lat to it)
• both art & n. run lat. to pisiform bone & medial to hook of hamate
Hand • divides into supf & deep branches
18
• supf branch: supplies palmaris brevis
• deep branch: supplies: hypothenar muscles
adductor pollicis
3rd & 4th lumbricals
all dorsal & palmar interossei
Branches
Arm no branches
Forearm 1. muscular : flexor carpi ulnaris
: med 1/2 of flexor dig profundus
2. dorsal cutaneous branch : dorsal aspect of med 1 1/2 fingers
: skin of med. 1/2 or less of dorsum
of hand
3. palmar cutaneous branch: skin of med aspect of palm
NOTE: In forearm - supplies flexor carpi ulnaris & med 1/2 of flexor dig
profundus
In hand - supplies all intrinsic muscles except thenar muscles & lat 2
lumbricals
- supplies med 1 1/2 fingers
Surface Marking
• In arm: pt 1: distal end of axillary artery
pt 2: post aspect of med. epicondyle
Join the 2 pts
• In forearm: extend this line to lat side of pisiform bone
Clinical Notes
Lesions at elbow & wrist
Radial Nerve
Origin
• from post cord of brachial plexus in axilla
• C5., 6, 7, 8, T1
Course
Axilla • begins at lower border of pect minor
• runs bhd 3rd part of axillary art, below axillary n
• passes btw long & lat heads of triceps
19
to enter post compartment of arm
Arm • after entering arm, passes btw lat. & med. heads of triceps
• enters radial groove
• accompanied by profunda brachii artery
• pierce lat intermuscular septum
& enters flexor compartment
• lies btw brachialis & brachioradialis
• crossed in front of lat. epicondyle
• in cubital fossa – divides into superficial & deep branches
Forearm & Hand
1. Superficial branch • smaller of the 2 branches
• passes ant to pronator teres & brachioradialis
• in middle 1/3 of forearm, lies lat to radial artery
• in lower part of forearm, leaves artery &
passes posteriorly deep to tendon of brachioradialis
• descends over abductor pollicis longus
& extensor pollics brevis tendons
• pass into hand superficial to extensor retinaculum
• supplies : lat 2/3 of post surface of hand
: post. surfaces of lat 3 1/2 fingers
up till the proximal phalanx
Branches
Axilla 1. post. cutaneous n of arm
2. n to long head of triceps
3. n to med head of triceps
Arm (spiral groove) 1. lower lat cutaneous n of arm
2. post cutaneous n of forearm
3. n to lat head of triceps
4. n to medial head of triceps & anconeus
Arm (ant compartment) 1. branch to brachialis
2. n to brachioradialis
3. n to extensor carpi radialis longus
Terminal Branches 1. superficial
(in cubital fossa) 2. deep (post interosseous)
Surface Marking
In arm: Pt 1: distal end of axillary artery
Pt 2: junction of upper & middle 1/3 of a line drawn from insertion of
deltoids to lat epicondyle
Join the 2 pts by an oblique line across back of arm
Further extend the line to front of lat epicondyle
Clinical Notes
Commonly damaged in axilla & in spiral groove
20
Lesion of radial n in spiral groove
Motor Effects
Paralysis of Effects
long extensors no extension at wrist jt – wrist-drop
brachioradialis & supinator
Sensory Effects
1. loss of sensation over base of thumb
21
Thorax
Intercostal Space
• Intercostal spaces are spaces btw ribs
• They contain 3 muscles and neurovascular bundle in costal groove
Intercostal Muscles
Ext Intercostals Int Intercostals Innermost Intercostals
Origin fr inf border of rib above costal groove of rib above
Insertn sup border of rib below sup border of rib below
Extent fr tubercle of rib bhd to fr sternum in front to angle of
costochondral jn (where it is rib (where it is replaced by int
replaced by ext i/c mbm) i/c mbm)
Others • discontinuous layer of muscles
• can be divided into 3 parts
1. tnvs thoracis (sternocostalis)
2. intercostalis intimus
3. subcostalis
• relation:
int: endothoracic fascis & parietal pleura
ext: i/c n & vsls
Intercostal Arteries
Post I/c Art • of 1st 2spaces: branches from sup i/c art
• of the lower 9 spaces: branches of thoracic aorta
• they enter costal groove at angle of eib & run along it
• at ant end of i/c space, anastomose with ant i/c art
• branches : dorsal branch
: collat branch
Ant I/c Art • of 1st 6 spaces: branches of int thoracic art
• of lower 5 spaces: branches of musculophrenic art
• 2 ant i/c art given off in each space
• anastomose with post i/c art
Intercostal Veins
Post i/c veins • correspond to the art & lie above them
• drain into azygos & hemiazygos veins
Ant i/c veins drain into int thoracic & musculophrenic veins
Intercostal Nerves
Origin • i/c n are the ventral rami of T1 to T11
• That of T12 is subcostal n
• However T1 contributes to brachial plexus
T3 to T6 = typical i/c n
T7 to T11 supply ant abd wall as well
Course • emerges bhd sup costotnvs lig
• lies btw pleura & int i/c vsls
• passes below neck of corresponding rib
• enters costal groove, lying below i/c vein & art
• runs in neurovascular plane btw inf & innermost i/c
• near midaxillary line, gives off
1. collat branch runs along upper border of rib below
2. lat cutaneous branch supplies side of trunk
• reaches ant end of i/c space
• runs forward thru int & ext i/c & pect major
• distributed as the ant cut branch to skin of chest
Branches 1. rami communicantes
2. collat branch
3. lat cut branch
4. ant cut branches
5. muscular branches
6. sensory branches
22
Clinical Notes
1. When aspirating fluid from i/c space, insert needle at centre of space in midaxillary line (usu 7th space) to avoid damaging n
& vsls
2. I/c n may be blocked with anaesthetic injected into the i/c space bhd post axillary line
Note: The i/c art, veins & nerves from the neurovascular bundle run in the corstal groove, with the vein most sup & n most
inf
Diaphragm
The diaphragm partitions the thorax from the abd.
It is musculotendinous in structure
Development
• central tendons from septum transversum
• peripheral muscular part from body wall mesoderm
• crura from dorsal meso-esophagus mesentery
• parts btw crura & costal origins from pleuroperitoneal mbm
Function
chief muscle of respiration
contract increases thoracic vol inspiration
Origin
Sternal slips attached to post surface of xiphoid process
Costal slips arising from inner aspects of lower 6 costal cartilages
Vertebral 1. right crus: fr bodies of L1 to L3
left crus: fr bodies of L1 & L2
2. med arcuate lig : thickening of psoas fascia
: btw body of tnvs process of L1
3. lat arcuate lig: from tnsv process of LV1 to middle of
lower border of 12th rib
Insertion
fibres pass upwards to insert into central tendons, which is trifoliate
Level
R dome upper border of 5th rib
L dome lower border of 5th rib
central tendon at level of xiphisternal jt
Nerve Supply
• motor supply = phrenic n only
• sensory supply = central part by phrenic n
peripheral part by lower 6 i/c n
Actions
1. muscle of inspiration
2. abd straining
3. wt lifting muscle
4. thoraco-abd pump
Openings in Diaphragm
Opening Transmits
Aortic Opening 1. aorta
2. thoracic duct
3. azygos vein
Esophageal Opening 1. esophagus
2. R & L vagus n
3. esophageal branch of L gastric vsls
4. lymphatics
Caval Opening 1. IVC
2. R phrenic n
23
Clinical Notes
1. diaphragmmatic hernias
2. accumulation of infected mat in subphrenic spaces
24
Movements of Thoracic Cage During Respiration
• Respiration consists of 2 phases 1) inspiration
2) expiration
• They are accomplished
1. by alternate increase & decrease of capacity of the thoracic cavity
2. by changes in vertical, antero-posterior & trnvs diameters
Quiet Inspiration
Vertical Diameter • increased mainly by contraction & descent of the diaphragm
• diaphragm is fixed inferiorly
1. by the 2 crura
2. by quad lumborum which fixes the 12th rib
• descent of diaphragm pushes the abd viscera, leading to forward movement of ant
abd wall
• also results in splaying out of lower ribs (8, 9, 10)
increase in tnvs diameter at this level
Antero-Post Diameter • increased by raising the ext ends of the downward-sloping ribs,esp the upper ribs
• 1st rib is fixed by scalene muscles
• intercostals contract
Transverse Diameter • increased by raising the downward-sloping lat portions of the ribs
• 1st rib fixed by scalene muscles
• contraction of the ext intercostals,
aided by interchondral portion of int intercostals
• lat portions of ribs raised
• axis of movement:
- passes antero-post from angle of rib bhd
to costochondral jn in front
• called the ‘bucket-handle’
Results of Movements
1. fall in intrathoracic P
2. air sucked into lungs
3. venous bld sucked into RA
4. lymph returned to neck veins via thoracic duct
Forced Inspiration
• normal movements amplified
• every muscle that can raise the ribs brought into action
eg. scalenus ant & medius
serratus ant & post (sup & inf)
levators costorum
sternocleidomastoid
• Note: In violent inspiratory effort, the pect. muscles can also come into play, provided their insertions are fixed.
Quiet Expiration
• Passive procedure
• brought about by: 1. elastic recoil of lungs
2. relaxation of i/c muscles & diaphragm
• also increase in tone of abd muscles, which force the diaphragm upwards
Forced Expiration
• mainly due to the forcible contraction of the muscles of the ant abd wall
• quad lumborum contracts & pulls down 12th ribs.
• other intercostals may also contract & depress the ribs
Course
• The trachea begins at the lower border of cricoid cartilage, at level of CV6
• It runs slightly backwards & downwards in the midline of the neck into the thorax where it divides into 2 main bronchi at
the lower border of TV4
25
6. aortic arch
7. deep cardiac plexus
Blood Supply
1. Inf thyroid art
2. bronchial art
3. pulm art
Venous Drainage
L. brachiocephalic vein
Lymphatic Drainage
pretracheal & paratracheal nodes
Nerve Supply
1. Symphathetic fibres by middle cervical ganglion
- reach via inf thyroid art
2. Psymph fibres by vagus thru recurrent laryngeal n
- they are a) sensory & secretomotor to mucus glands
b) motor to trachealis muscles
Applied Antomy
1. tracheostomy
2. displacement / compression due to pathological enlargement of surrounding structures, eg effusion & collapsed lungs
Bronchi
Right Left
• wider • narrower
• shorter • longer
• more vertical • more horizontal
• gives sup lobar bronchus • passes below aortic arch
• enters hilum at TV5 in front of esophagus & desc aorta
• enters hilum at TV6
Pleura
Parts of Pleura
• 2 parts: parietal pleura (outer layer)
visceral pleura (inner layer)
separated by pleural cavity containing pleural fluid
• For descriptive purposes, the parietal pleura is divided into:
1. cervical pleura
2. costal pleura
3. mediastinal pleura
4. diaphragmatic pleura
Reflections
Lines of reflection are sites where costal pleura becomes continuous with mediastinal pleura anteriorly & posteriorly, & with
diaphragmatic pleura inferiorly
Reflections Remarks
Sternal Reflections • Costal pleura is continuous with mediastinal pleura
• R & L sternal reflections are indicated by lines that pass inferomed from sternoclavicular jts
to the median line at level of sternal angle
• Here the 2 pleurae come into contact & may overlap slightly
• R side: sternal reflection continues inferiorly in the midline
to the post aspect of xiphoid process
• L side: sternal relection continues inferiorly
in the midline to 4th costal cartilage;
Here, it passes to L margin of sternum
& continues to the 6th costal cartilage
Costal Reflections • Costal pleura is continuous with diaphragmatic pleura near the chest margin
• The line passes obliquely across: 8th rib in midclavicular line
10th rib in midaxillary line
12th rib in its neck
Vertebral Reflections Costal pleura is continuous with mediastinal pleura along a vertical line just ant to the heads of 1st to
12th ribs
Mediastino- Mediastinal pleura is continuous with diaphragmatic pleura along the line connecting the inf ends of
diaphragmatic the sternal & vertebral reflections
26
Reflections
Cervical Pleura • Costal & mediastinal parts of the parietal pleura are continuous over the apex of the lung to a
cupola / dome.
• The cupola of the pleura & the apex of the lung are related to the 1st rib posteriorly
but is 3 cm or more higher than the med 1/3 of the clavicle, which is its ant relation
Parietal-Visceral • This happens at the root of the lung
Reflections • The parietal pleura becomes continuous with the visceral pleura
• Below the root of the lung, the mediastinal pleura turns laterally as a double layer called the
pulm. lig
• it allows for the movement of the root of the lung as well as expansion of BV
Visceral Pleura
• It is normally firmly adherent to the surface of the lung
& closely follows its contours, also dipping into the fissures
Recesses
Recess Remarks
Costomediastinal Parts of the pleural cavity btw 2 layers of parietal pleura at the sternal reflection
Costodiaphragmmatic Part of the pleura cavity btw 2 layers of parietal pleura at the costodiaphragmmatic
reflection
Note: Lung extends into both recesses during quiet inspiration
Surface Marking
Cervical Pleura • curved line forming a dome over med 1/3 of clavicle with ht of abt 3 cm
Ant Margin
1. Right • sternoclavicular jt
• midline at sternal angle
• midline to level of 4th costal cartilage
• midline to level of 6th costal cartilage
2. Left • sternoclavicular jt
• midline at sternal angle
• midline at 4th costal cartilage
• then runs along L margin of sternum to 6th costal cartilage
Inf Margin • from lower limit of ant margin
• 8th rib at midclavicular line
• 10th rib at midaxillary line
• 12th rib at paravertebral line
Post Margin joins a pt 2 cm lat to the 12th thoracic spine to a pt 2 cm lat to C7 spine
27
- passes upwards from ant - L common carotid lies in front of L subclv
4. groove for IVC 4. groove for desc aorta
- in front of pulm lig - in front of post border of lung bhd hilus
5. groove for esophagus 5. groove for esophagus
- in front of groove for - in front of lower part of groove for desc
6. grooves for R subclv art & vein aorta
- at apex of lung
At Hilus From above downwards From above downwards
1. sup lobar branches 1. pulm art
2. pulm art 2. inf lobar bronchus
3. inf lobar bronchus 3. inf pulm vein
4. inf pulm vein
Pericardium
It is a fibroserous sac that encloses the heart & the roots of the great vsls
It is situated in the middle mediastinum
Pericardial Cavity
• potential space btw the parietal & visceral layers
• contains fluid for lubrication during beating of the heart
Blood Supply
1. int thoracic art & veins
2. musculophrenic vsls
3. desc aorta
Nerve Supply
1. phrenic n - supplies both fibrous & parietal pericardium
- pain fibres
2. cardiac plexus - supplies the epicardium
- pain insensitive
Clinical Notes
1. constrictive pericarditis & pericardidis with effusion causes ‘cardiac tamponade’, where the heart cannot dilate freely
2. pericardiac effusion can be drained at the angle btw the xiphoid process & the L costal margin (ie cardiac notch)
prevent damage to lung
Apex • formed by LV
• at 5th i/c space, 3 1/2 inches from midline
Sup Border • formed by rootes of great BV
• extends btw
pt 1 = lower border of 2nd L costal cartilage
1/2 inch from edge of sternum
pt 2 = upper border of 3rd R costal cartilage
28
1/2 inch from edge of sternum
R Border • formed by RA
• extends btw
pt 2 = upper border of 3rd R costal cartilage
1/2 inch from edge of sternum
pt 3 = 6th R costal cartilage
1/2 inch from edge of sternum
L Border • formed by LV
• extends btw
pt 1 = lower border of 2nd L costal cartilage
1/2 inch from edge of sternum
apex
Inf Border • forward by RV & apical part of LV
• extends btw
pt 3 = 6th R costal cartilage
1/2 inch from edge of sternum
apex
Relations
Post Surface (Base) 1. pericardium
2. R pulm veins
3. esophagus
4. aorta
• These sep it from (TV5-8 or TV6-9)
• The 4 pulm veins (2 on each side) open into the LA
• The SVC opens into sup part
IVC opens into inf part of RV
Ant Surface (Sternocostal) 1. pericardium, which sep it from
2. body of sternum
3. sternocostalis muscle
4. 3rd & 4th costal cartilage
It is also covered by
5. pleura
6. thin ant parts of lungs
Inferior Surface (Diaphragmatic) rests upon
1. central tendon
2. small part of L muscular portion of diaphragm
Left Surface 1. serous pericardium, which sep it fr
2. L phrenic n
3. pericardiacophrenic vsls
4. L pleura, which sep it from
5. L lung (below & in front of hilus)
Right Surface 1. serous pericardium, which sep it fr
2. R phrenic n
3. pericardiacophrenic vsls
4. R pleura, which sep it from
5. R lung
Clinical Notes
Due to position & relations of the heart, it is best to approach from the front for:
1. aspiration of pericardial fluid
2. drainage of pericardial effusion
29
Heart: Internal Features
Right Atrium
General Features
• Consists of 2 parts:
1. smooth post part (derived from sinus venosus in embryo
2. rough ant part (derived from atrium proper)
• The 2 parts separated by muscular ridge = crista terminalis
rep on surface as sulcus terminalis
• from the crista terminalis arise muscular bands = musculi pectinati
which run forward from the crista towards the auricle
• SA node lies near upper end of sulcus terminalis, to the RHS of opening of SVC
Openings into RA
SVC • opens into upper part
• no valves
IVC • opens into lower part
• rudimentary valve
coronary sinus • opens btw IVC & AV orifice
AV orifice • ant to IVC
• guarded by tricuspid valve
Note: Also present are openings for small veins which drain the wall of the heart
Clinical Notes
• Atrial septal defect usually a patent foramen ovalis
Right Ventricle
Openings
AV orifice • Communicated with R atrium
• Guarded by tricuspid valve
Pulm orifice • opens into pulm trunk
• guarded by pulm valve
• near pulm orifice, the ventricular cavity becomes funnel-shaped
infundibulum
General Features
• wall of infundibulum is smooth
• rest of ventricular wall is rough due to projecting ridges
called trabeculae carneae
• bridge-like projecting structure also found,
being attached to both ends & free in the middle
moderator band • passes from i/v septum to ant wall of RV
• conveys R br of AV bundle
papillary muscles • arise from ventricular wall & project into lumen
• apex gives rise to fibrous cords (chordae tendinae) which are inserted into the
margins of the tricuspid valve cusps
prevent cusps from being driven into RA during ventricular contraction
• 3 papillary muscles present = ant, post, septal
prominent ridges
• infundibulum separated from rough part of ventricle by supraventricular crest
Interventricular Septum
• consists of 2 parts: 1. membranous part
2. muscular part
Valves
tricuspid valve • gurads AV orifice
• consists of 3 cusps: ant, inf & septal
• cusps formed by fold of endocardium with fibrous tissue enclosed
30
• attached to fibrous ring around AV orifice
skeleton of heart
pulm valve • guards pulm orifice
• consists of 3 semilunar cusps formed by folds of endocardium enclosing fibrous tissue
• situated ext to each cusp are dilations
sinuses
• the cusps are: ant, R & L
prevent backflow of bld from pulm trunk
Clinical Notes
1. pulm valve stenosis
2. pulm valvular incompetence heart murmur
31
Left Ventricle
• forms - apex
- L border
- diaphragmatic surface of heart
• muscular wall 3 times as thick as RV
General Features
• smooth upper part = aortic vestibule
• rest of ventricular wall is rough due to
projecting ridges called trabeculae carneae
• papillary muscles - arise from ventricular wall & project into lumen
- apex gives rise to chordae tendinae which are inserted into margins of mitral valve cusps
prevent cusps from being driven into LA during ventricular contraction
- 2 papillary muscles = ant, post
• no moderator band
Interventricular Septum
• consists of 2 parts: 1. membranous
2. muscular
• bulges into RV
Openings
AV orifice communicates with LA
guarded by mitral valve
aortic orifice opens into aorta
guarded by aortic valve
Both openings are surrounded by fibrous rings which give attachment to the valve cusps
skeleton of the heart
Valves
mitral valve • guards AV orifice
• consists of 2 cusps = ant & post
• cusps formed by fold of endocardium enclosing fibrous tissue attached to fibrous ring around AV
orifice
skeleton of heart
aortic valve • guards aortic orifice
• consists of 3 semilunar cusps = ant, post, L
• bhd each cusps = aortic sinus
ant sinus R coronary art
post sinus L coronary art
Function of valves – prevent backflow of bld from aorta
Clinical Notes
1. mitral valve disease to incompetence heart murmur
2. aortic valve stenosis
3. aortic valve incompetence heart murmur
Heart: Conducting System
• The heart possesses a conducting system which conducts impulses rapidly to all parts of the heart
• The impulses originate in the SA node, ie within the conducting system
• The conducting system is made up of specialized cardiac tissue
Purkinje fibres
• Components of conducting system
1. SA node
2. AV node
3. AV bundle (of His) – R & L terminal branches
4. subendocardial plexus of Purkinje fibres
Sino-Atrial Node
• found in upper part of sulcus terminalis just to the R of opening of SVC in RA
• site of initiation of cardiac impulses pacemaker
• contains network of specialized cardiac fibres that are
continuous with the muscle fibres of the atrium
• cardiac impulses spread through atrial myocardium to reach the AV node
Atrio-Ventricular Node
• found in lower part of atrial septum just above
attachment of septal cusp of tricuspid valve
• contains network of specialized cardiac fibres that arecontinuous with both atrial muscle & ventricular bundle (of His)
links atrium & ventricle
• impulses are then conducted to AV bundle
32
Atrio-Ventricular Bundle (of His)
• strand of specialized conducting muscle fibres
• arise from AV node
• runs ant to membranous part of i/v septum
• divides into R & L branches
Right branch • passes down R side of i/v septum
• reaches moderator band
• crosses to ant wall of RV
• ends in subendocardial Purkinje plexus
supplies RV
Left branch • pierces i/v septum
• passes down L side of septum
• divides into 2 branches
• ends in purkinje plexus
supplies LV
• The AV bundle & its branches are surrounded by fibrous sheaths which isolate them from the myocardium
Purkinje Plexus
• These are found in the subendocardial regions of the ventricles
• The Purkinje fibres (specialized conducting tissues) enable the impulse to spread rapidly throughout the ventricles
Blood Supply
SA node R & L coronary art
AV node R coronary art
AV bundle R coronary art
R branch of AV bundle R coronary art
L branch of AV bundle R & L coronary art
Nerve Supply
symp & psymp fibres from cardiac plexus
symph fibres from symp trunk
psymp fibres from vagus n
Clinical Notes
• passage of impulses over heart from SA node can be recorded as an ECG
• artificial pacemakers
Clinical Notes
• Occlusion of one of the arteries myocardial infarction
• although anastomosis btw the 2 arteries occur,
they are not large enough to maintain collat circulation
• if blockage is gradual, collat circulation can sometime be viable
33
Venous Drainage
• coronary sinu receives most of the venous drainage of the heart
opens into RA
• most of the bld returned via
great cardiac vein accompanies ant i/v art
middle cardia vein accompanies post i/v art
small cardiac vein accompanies marginal branch of R coronary art
• the rest of the bld is returned via
1. ant cardiac vein
2. small veins that open directly into the heart chambers
Relations
Anteriorly From front to back
1. L phrenic n
2. inf cervical cardiac br of L vagus
3. sup cervical cardiac br of L symp
4. trunk of L vagus
(As the L vagus crosses the arch, it gives off recurrent laryngeal br which hooks round below the arch)
5. sup intercostals vein
These structures are sep fr chest wall by
6. L lung & pleura
7. remains of thymus gld
Posteriorly 1. trachea
2. tracheobronchial lymph nodes
3. deep cardiac plexus
4. L recurrent laryngeal n
5. esophagus
6. thoracic duct
7. vertebral column
Superiorly branches of the arch from R to L, & from front to back
1. brachiocephalic trunk
2. L common carotid art
3. L subclavian art
These are crosses in front by:
4. L brachiocephalic vein
Inferiorly 1. bifurcation of pulm trunk
2. L principal bronchus
3. ligamentum arteriosum
4. supf cardiac plexus
5. L recurrent laryngeal n
Branches
1. brachiocephalic trunk
2. L common carotid artery
3. L subclavian art
Clinical Notes
1. immediately distal to origin of L subclavian art
narrowing of aortic arch known as aortic isthmus
commonest site of coarctation of aorta
2. aorta is also common site for aneurysm
Brachiocephalic Trunk / Artery
This is the largest branch of the arch of aorta & is abt 4 to 5 cm in length
Origin
• arises from convexity of arch of aorta
pst to centre of manubrium sterni
• passes obliquely upward, backward & to the R
• lies in front of trachea, then on its R
• at level of upper border of R sternoclavicular jt
divides into R common carotid & R subclavian art
34
Relations
Anteriorly It is separated from manubrium sterni by
1. sternohyoid
2. sternothyroid
3. remains of thymus
4. L brachiocephalic vein
5. R inf thyroid vein
6. cardiac branches of R vagus
Posteriorly 1. trachea
2. R pleura
3. R vagus
Right 1. R brachiocephalic vein
2. upper part of SVC
3. R pleura
Left 1. remains of thymus
2. origin of L common carotid artery
3. inf thyroid veins
4. trachea
Branches
only 2 terminal branches
1. R common carotid artery
2. R subclavian artery
Pulmonary Trunk
Origin
from conus arteriosus (infundibulum) of RV
Course
• directed superiorly & posteriorly
• length = ∼5cm; runs in front of asc aorta, then to its L
• divides into R & L pulm arteries
Note: It lies in the middle of mediastinum
& is invested in a sheath of serous pericardium
Relations
Anteriorly Posteriorly Right Left
sep fr L 2nd i/c space by 1. asc aorta 1. R auricle 1. L auricle
1. L lung & pleura 2. L coronary art 2. R coronary art 2. L coronary art
2. pericardium 3. LA 3. asc aorta
Branches
1. R pulm artery - larger & longer than L
- passes below arch of aorta
- divides into 2 branches
2. L pulm artery - runs in front of bronchus
- divides into 2 branches
- connected to concavity of aortic arch by lig arteriosum
Surface Marking
It is indicated by a line joining the following 2 pts:
pt 1 = at upper part of cardiac outline
pt 2 = at L side of sternal angle, bhd L 2nd costal cartilage
Clinical Notes
1. patent ductus arteriosus
2. pulm embolism blocks pulm art
3. congenital stenosis of pulm trunk
Azygos Vein
• The azygos system of veins drain blood from the back
& from the thoracic & abd walls
• This system includes the azygos, hemiazygos, & accessory hemiazygos v.
• The azygos vein drains mainly blood from the R side
Origin
• commences in abd as R asc lumbar vein
• lies to the R of aorta, with thoracic duct in btw
• asc on the vertebral bodies in the post mediastinum
• at TV4, it arches forward over root of R lung
• enter SVC at level of R 2nd costal cartilage
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Relations
Anteriorly Posteriorly Right Left
1. R pleura 1. bodies of lower 8 TV 1. R greater splanchnic 1. thoracic duct
2. esophagus 2. ant long lig n 2. aorta
3. root of R lung 3. R post i/c art 2. R lung & pleura when it arches forward over root of
R lung,
3. esophagus
4. trachea
5. R vagus
Tributaries
1. R post intercostals veins (except 1st)
2. hemi-azygos & accessory hemi-azygos
3. several esophageal, mediastinal & pericardial veins
4. R bronchial veins
Valves
• a few imperfect valves
• tributaries provided with complete valves
Clinical Notes
• Anastomoses among the caval, azygos & vertebral venous systems provides multiple routes for return of blood to the heart
• The azygos & vertebral systems bypass the vena cavae
maintain circulation even if vena cava obstructed
Phrenic Nerves
• The phrenic n supplies the diaphragm (motor & sensory)
• It also sends sensory fibres to the pericardium, part of the pleura & peritoneum as well as capsule of liver.
Origin
• in the neck
• C3, 4, 5
Clinical Notes
1. pain over the area of supply is referred to skin over the shoulder & lower part of neck
2. the phrenic n is the only motor supply of the diaphragm
lesion will lead to paralysis of diaphragm
Vagus Nerves
• The vagus nerves possess many functional components
• It has an extensive course & distribution
• In the thorax the vagus provides PreGN psymp fibres to the viscera
& these terminate by synapsing with n cells
in or near structures to be innervated
Origin
10th cranial nerve
Course Branches in Thorax
Right • enters thoracic cavity by passing btw R subclavian art & vein 1. R recurrent laryngeal n
Vagus • desc on lat side of trachea - arises where the vagus passes
• reaches back of root of lung in front of R subclavian art
contributes to R post pulm plexus - hooks below the art. then bhd
• R vagal fibres then pass downwards it
- asc btw trachea & esophagus
• communicate with corresponding branches fr L vagus to form
into the neck
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esophageal opening 2. branches to bronchi & esophagus
• from post part of esopahgeal plexus, R vagal fibres regp to form a
single n bundle
• desc along post surface of esophagus
• enters abd thru esophageal opening in diaphragm
Left • enters thoracic cavity btw L common carotid & L subclavian art 1. L recurrent laryngeal n
Vagus • crosses L side of arch of aorta - hooks around ligamentum
• reaches back of root of lung arteriosum
contributes to L post pulm plexus - asc btw trachea & esophagus
• L vagal fibres then pass downwards on R side of aortic arch
- enters neck
• communicate with branches of R vagus to form esophageal plexus
2. branches to bronchi & esophagus
• from ant part of plexus, L vagal fibres regp to form single n
bundle
• desc along ant surfaces of esophagus
Clinical Notes
L recurrent laryngeal n liable to be damaged by disorders of aorta
(eg aneurysms) or mediastinum (eg tumours)
Thoracic Duct
• It is the largest lymphatic vessel in the body
• It is thin-walled & supplied by many valves
Course
• leaves abd & enters thorax via aortic opening
to the R of aorta & L of azygos vein
• asc in post mediastinum lying on thoracic vertebral bodies
& post to esophagus
• at level of TV5, it turns to the L & reaches L side of esophagus
at level of TV4
• from here, asc till it reaches neck
• it then makes a loop at level of CV6
& desc to join the jn btw int jugular & L subclavian vein
Relations
Anteriorly Posteriorly Right Left
In Neck 1. carotid sheath with 1. symp trunk
vagus n 2. vertebral vsls
3. L phrenic n
4. L subclavian art
In Thorax 1. esophagus 1. thoracic vertebra 1. azygos vein 1. aorta
2. post i/c art 2. esophagus 2. L pleura
Tributaries
Tributaries Drainage of
At its origin 1. intestinal lymph trunk gut
2. lumbar lymph trunk 1. other abd & pelvic viscera
2. lower limb
3. abd wall
In the thorax 1. post mediastinal nodes L thorax
2. mediastinal lymph trunk
In the neck 1. L jugular lymph trunk L head & neck
2. L subclavian lymph trunk L upper limb & L axilla
Hence it drains the whole body except R head & neck, R upper limb & R thorax
(which are drained by R lymphatic duct)
Clinical Notes
infection of lymph trunk chylous ascites
injury to duct in neck surgery chylous fistula
fracture of thoracic vertebra chylothorax
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Ganglia
• normally described as having 2 ganglia
• usu less due to fusion of adj ganglia
• 1st ganglia usu fused with inf cervical ganglia to form stellate ganglion
• each ganglion receives a white ramus from its corresponding spinal n;
after relay a PGN grey ramus is given to each of the n
Branches
1. GRC - to all thoracic spinal n.
- distributed to all BV, sweat glds & arrector pili muscles of skin
2. 1st 5 ganglia give PGN fibres to heart, aorta, lungs & esophagus
- form plexuses tog. with fibres from vagus n
ie cardiac plexuses
pulmonary plexuses
esophageal plexuses
3. Splanchnic Nerves
Greater splanchnic n ganglia 5-9
Lesser splanchnic n ganglia 10-11
Least splanchnic n ganglia 12
These supply abd viscera
Clinical Notes
1. PreGN sympathectomy - causes vasodilation
- effects are 1) high bld flow
2) lowering of blood pressure
2. removal of ganglia (eg upper 4-5) - interrupts pain fibres
- relieves severe pain
3. high spinal anaesthetic may block PreGN symp fibres
Curvatures
• generally vertical, corresponds to curvature of thoracic spine
• curves to L when approaching esophageal opening
Constrictions
3 in thorax
1. where it is crossed by aortic arch CV6
2. where it is crossed by L bronchusTV4
3. where it pierces diaphragm TV10
Relations
Anteriorly 1. L recurrent laryngeal n
2. trachea
3. L bronchus
4. R pulm art
5. pericardium & LA
Posteriorly 1. vertebral column along most of its length
2. thoracic duct
(as it crosses from R to L at TV5 or 6)
3. azygos vein
4. thoracic aorta (lower part)
5. R post i/c art
Right 1. R lung & pleura
2. R vagus n
3. azygos vein as it hooks over R bronchus
Left 1. L lung & pleura
From above downward,
2. L vagus n
3. thoracic duct
4. arch of aorta
5. L subclavian art
6. desc aorta
Blood Supply
largely by 4 unpaired median branches from aorta
cervical part inf thyroid art
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thoracic part azygos art
abdominal part L gastrinc art
Venous Drainage
into azygos vein
cervical part brachiocephalic vein
thoracic part azygos vein
abdominal part L gastric vein
Lymphatic Drainage
1. post mediastinal nodes
2. deep cervical (upper part)
3. abd nodes (lower part)
Nerve Supply
Parasympathetic • sensory, motor & secretomotor
• upper 1/2 - by recurrent laryngeal n
lower 1/2 - by esophageal plexus
Sympathetic • vasomotor
• upper 1/2 - by middle cervical ganglion
via inf thyroid art
lower 1/2 - by upper 4 thoracic ganglion via
esophageal plexus
Clinical Notes
1. In portal hypertension, esophageal varices develop due to dilation of porto-systemic anastomses at lower end of esophagus
2. mediastinal syndrome leads to compression of esophagus
causes dyspahgia
Abdomen
Rectus Sheath
The rectus sheath is a long sheath enclosing the rectus abd & pyramidis muscles, on ant abd wall
Components
It is formed by the aponeuroses of the 3 lat abd muscles
1. ext oblique
2. int oblique
3. tnvs abdominis
Description
It is considered at 4 levels
Level Ant Wall Post Wall Remarks
Above the aponeurosis of ext thoracic wall
costal margin oblique ie 5th, 6th & 7th costal cartilages &
i/c spaces
muscular apo def post
Btw costal 1. aponeurosis of ext 1. post lamina of int oblique • The int oblique apo splits to enclose
margin & level oblique 2. tranversus abdominis the muscle
of ASIS 2. ant lamina of int • Inf border of post wall is free
oblique =arcuate line
At this site, the inf epig vsls enter the
rectus sheath & pass upwards to
anatomose with sup epigastric vsls
Btw level of aponeuroses of all 3 deficient rectus muscle lies in contact with fascia
ASIS & pubis muscles transversalis
In front of aponeuroses of all 3 body of pubis • The rectus sheath is sep from its
pubis muscles fellow on oppo side by the linea alba
cover origin of extending from xiphoid process down
to the symphysis pubis
• The ant wall of the sheath is attached
to rectus muscle by its tendinous
insertions while the post wall is not
attached to the muscle
Contents
1. rectus abdominis & pyramidis
2. ant rami of lower 6 thoracic n & art
3. sup & inf epigastric vsls
4. lyphatics
Inguinal Canal
• It is an oblique passage through lower part of ant abd wall
• In male, it permits structures to pass to & from testis (via spermatic cord)
39
• In female, it transmits round lig of uterus
• It also transmits the ilioinguinal n in both sexes
Extent
• from deep inguinal ring to supf inguinal ring
ie passes forward anteromedially
• it is parallel to & above the inguinal lig
Inguinal Rings
Deep Inguinal Ring • oval opening in transversalis fascia
• midway btw ASIS & symp pubis
• margins give rise to int spermatic fascia
• related med to inf epigastric vsls
Supf Inguinal Ring • triangular opening in ext oblique aponeurosis
• immediately above pubic tubercle & med end of ing lig
• the opening extends superolat
• base at pubic crest
• crura margins give rise to ext spermatic fascia
Walls of Canal
Anterior Wall formed by apo of ext oblique
reinforced along lat 1/3 by fibres of int oblique
strongest part lies oppo deep ing ring
Posterior Wall • formed by fascia transversalis
• reinforced along med 1/3 by conjt tendon
strongest part lies oppo deep ing ring
Floor • formed by ing lig & lacunar lig
Roof • formed by the arching lowest fibres of int oblique & transversus abd
muscles
Spermatic Cord
Coverings Contents
1. ext. spermatic fascia 1. vas deferens
2. cremaster muscle & fascia 2. testicular art, cremasteric art, art to vas deferens
3. int spermatic fascia 3. pampiniform plexus of veins
4. lymph vsls
5. symp n fibres
6. genital br of genitofemoral n
7. remains of processus vaginalis
Clinical Notes
Weak areas are the supf & deep ing rings herniation
Indirect Ing Hernia • viscera enter deep ing ring & travel along canal
• emerge from supf ring & into scrotum
• accompanied by sac of peritoneum
Direct Ing Hernia • viscera protrude anteriorly
• usu passes through inguinal (Hassalbach’s) triangle
Relations
Posterior Relations 1. erector spinae lies bhd the quadratus lumborum
2. more superficially = lat dorsi
40
3. thoracolumbar fascia
Lateral Relations 1. origins of int oblique & trannsversus abd from thoracolumbar fascia lie at lat edge of
quadratus lumborum
Anterior Relations Related to structures in abd cavity
1. aorta
2. IVC
These lie on the front of the vertebral bodies,
with psoas minor at their sides
3. crura of diaphragm partly cover the upper LV
4. med arcuate lig of diaphragm bridges psoas major
5. lat arcuate lig of diaphragm bridges quadratus lumborum
6. abd part of symp trunk passes bhd med arcuate lig
7. lumbar plexus lies in psoas major
8. cisterna chyli lies in front of L1 & L2 (on R side of aorta)
9. kidneys & suprarenal glds lie below the arcuate lig
10. lower down,
R = cecum & asc colon
L = desc colon
Elsewhere the wall is line by parietal peritoneum
Lesser Sac
The lesser sac is a large bursa which facilitate the movements of the stomach
Subdivision
• The chief subdivisions are the sup & inf recesses
• These are separated from each other by a constricted area (vestibule) which lie btw the L & R gastropancreatic folds
• An extension of the sac towards the hulum of the spleen is called the splenic recess
Sup Recess lies bhd lesser omentum & caudate lobe of liver
Inf Recess lies bhd stomach & btw the layers of greater omentum
Splenic Recess lies btw gastrosplenic lig in front & lieno-renal lig bhd
Relations
Anteriorly 1. lesser omentum
2. caudate lobe of liver
3. post surface of stomach
4. ant 2 layers of greater omentum
Posteriorly 1. aorta & br
2. diaphragm
3. L kidney
4. pancreas
5. post 2 layers of greater omentum
Left 1. L margin of greater omentum
2. Ligaments: gastrosplenic
gastrohepatic
lienorenal
Right 1. peritoneal reflection from caudate lobe of liver to post abd wall
2. R margin of greater omentum
Inferiorly 1. lower margin of greater omentum
Openings
• The part of the lesser sac bhd the lesser omentum communicates
with the greater sac via the epiploic foramen (Foramen of Winslow)
• Boundaries of Epiploic Formen (of Winslow)
anteriorly • the free border of lesser omentum
• containing 1. bile duct
2. hepatic duct
3. portal vein bhd
posteriorly IVC (covered with peritoneum)
superiorly caudate process from caudate lobe of liver
inferiorly 1st part of duod
Clinical Notes
1. Intra-abdominal herniation of intestine through epiploic foramen
2. spread of infections & fluids / accumulation of fluids
41
Shape
It is roughly J-shaped, with 2 curvatures
lesser curvature • forms R border of stomach
• concave
• extends from cardiac orifice to pylorus
• near pylorus, notch = incisura angularis
greater curvature • forms L border of stomach
• covex
• extends from L of cardiac orifice
over fundus inf part of pylorus
Openings
cardiac orifice entry of esophagus
pyloric orifice (pylorus) • opens into duod
• controlled by pyloric sphincter around pyloric canal
Divisions / Parts
The stomach is divided into a fundus, body & a pyloric part
Fundus • dome-shaped
• projects upward & to the L from cardiac orifice
• sep from body by horizontal line
joining cardiac orifice to greater curvature
• usu full of gas
Body extends from level of cardiac orifice to level of incusura angularis
Pyloric Part subdivided into
1. pyloric antrum = proximal part
2. pyloric canal = distal part
= thick wall pyloric sphincter
Peritoneal Relations
• lesser omentum descends from liver to lesser curvature of stomach
called gastrohepatic lig
• at lesser curvature, the 2 layers of lesser omentum separate
cover ant & post surface
• except ‘bare area’ near cardiac orifice where
it is in direct contact with L crus of diaphragm
• on L upper part of greater curvature, the 2 layers meet & continue to diaphragm & spleen
gastrophrenic lig
gastrosplenic lig
• on lower part of greater curvature, the 2 layers meet &
continues downwards as ant 2 layers of greater omentum
Clinical Notes
1. fundus contains air percussion will produce tympany
Thus dullness over this area means: 1. enlarged L lobe of liver
2. enlarged spleen
3. L pleural effusion
2. porto-systemic anatomosis at lower end of esophagus & near cardiac opening
esophageal varices may occur
3. congenital pyloric stenosis
ie. hypertrophy of pyloric sphincter
4. greater omentum ‘walls off’ sites of infection
Stomach: Relations
• The stomach is situated in upper part of abd.
extending from L hypochondrium to epigastric & umbilical regions
• The stomach is relatively mobile (except at cardiac orifice)
& its position may vary
• The relations described are thus the more typical ones.
42
3. spleen : related to fundus as well as body
: sep from stomach by greater sac
4. L kidney : retroperitoneal
5. L adrenal gld: retroperitoneal
6. desc aorta : slightly to R of midline
: related to pylorus
7. pancreas : related to pylorus & body
8. mesocolon : related to lower part of body of stomach
: stretches from hepatic flexure to splenic flexure
9. middle colic art: btw layers of mesocolon
10. transverse colon : variable
: may be related to greater curvature
11. splenic flexure
Clinical Notes
1. perforation of post wall of stomach caused by ulcer can cause perforation of splenic art bleeding
2. fluid accumulation in lesser sac forward displacement of stomach
Arterial Supply
1. The gastric arteries
L gastric art • arises from celiac trunk
• desc along lesser curvature of stomach
R gastric art • arises from hepatic art at upper border of pylorus
• runs to the L along lesser curvature
- The 2 arteries anastomse to forma double channel
along lesser curvature & supplies it
- They lie in the lesser omentum & send branches through the muscles & submucosa to supply the mucosa directly
2. The gastro-epiploic arterires
L gastro-epiploic art • arises from splenic art
• runs along gastrosplenic lig &
to the R along greater curvature
R gastro-epiploic art • arises from gastroduod art (br of hepatic art)
• runs to the L along greater curvature
- The 2 arteries anastomose to form a channel along the greater curvature & supply it.
- They lie in the greater omentum, abt 1 cm from greater curvature
- They send branches into the ant & post walls of the stomach
& these may anatomose with branches fro lesser curvature
Venous Drainage
• The veins arise from a supf network of capillaries which form a plexus in the submucosa
• The veins terminate as follows:
1. L & R gastric veins drain into portal vein
2. L gastro-epiplocic & short gastric veins drain into splenic vein
3. R gastro-epiploic vein drains into sup mesenteric vein
Clinical Notes
• The extensive anastomosis provides good collat circulation
• Thus ligation of one of the major arteries will not have a great effect on the circulation
Stomach: Lymphatic Drainage
Lymphatic cap arising from mucosa form a submucous plexus
from which LV arise to follow BV
Zones of Drainage
The zones of drainage are indicated thus:
- a line drawn from highest pt of fundus to pylorus
ie divides stomach into upper 2/3 & lower 1/3
- the lower part is subdivided into L & R halves
43
Lymph Nodes
Clinical Notes
- spread of cancer
Sympathetic Supply
PreGN fibres • arise from T6-T12 segments of sp cord from ILN (lat horn)
• leaves sp cord along ventral roots of spinal n
• enter symp trunk via WRC
• without synapsing, leave symp trunk via splanchnic n
• synapse at celiac ganglia with post-synaptic neurons
PGN fibres • from celiac ganglia, follow branches of celiac trunk
• enter stomach tog with branches of vagi
• terminate in myenteric & submucosal plexuses
Parasympathetic Supply
Anterior (Left) Vagal • enter abd in front of esophagus
Trunk • gives off hepatic branches
• from which pyloric branches may arise to supply pyloric region
• the trunk then divides into branches which supply body of stomach
Posterior (Right) Vagal • enters abd bhd esophagus
Trunk • divides into branches which supply body of stomach
• large branch passes to celiac plexus where its branches are distributed as far as splenic flexure
of colon & pancreas
Clinical Notes
1. pain fibres accompany symp fibres
Thus sympathectomy may be performed to relieve pain
2. pain is referred to epigastrium
3. vagotomy may be performed to lower secretion of acid
esp when peptic ulcer present
Duodenum
The duod is the proximal part of the small intestine.
It is also the shortest & most fixed part
Course
• extends from pylorus to duod-jej flexure
• ∼ 25 cm
• forms a C-shape, the concavity of which is occupied by the pancreas
• its course can be described in 4 parts: sup, desc, horiz, asc
44
• runs down vertically to R of LV2 & LV3
• Relations:
Anteriorly Posteriorly Superiorly Inferiorly
1. fundus of GB 1. hilus of R kidney 1. asc colon 1. head of pancreas
2. R lobe of liver 2. commencement of R 2. R colic (hep) 2. bile duct & main pancreatic
3. tnvs colon ureter flexure duct pierce the wall abt
4. coils of SI 3. R lobe of liver halfway down post medial
aspect
3. accessory pancreatic duct
Blood Supply
proximal part sup pancreaticoduod art
(to opening of bile duct) (from gastroduod art)
distal part inf pancreaticoduod art
(from sup mes art)
Venous Drainage
Veins correspond to arteries
• sup veins drains into portal vein
• inf veins drains into sup mesenteric vein
Thus the venous drainage is ultimately into the portal vein
Lymphatic Drainage
upwards 1. sup pancreaticoduod nodes
2. gastroduod nodes
& thence into celiac nodes
downwards inf pancreaticoduod nodes
& thence to sup mesenteric nodes
into pyloric nodes from 1st part of duod
Nerve Supply
symp & psymp fibres from celiac & sup mesenteric plexuses
Clinical Notes
1. duodenal ulcer produced by acid chyme from stomach
esp. on anterolat wall of 1st part of duod
2. ulcer on post wall of 1st part of duodenum may erode gastroduodenal art
hemorrhage
45
3. mucous mbm folded plicae circulares in lower ileum, absent
folds are larger, more numerous & closely set
4. jejunal mesentery attached to post abd wall & to the L 4. ileal mesentery attached to lower part of post abd wall & to
of aorta the R of aorta
5. bld supply : fewer arcades 5. bld supply : several arcades
: long infreq branches : numerous short branches
6. fat deposits: mostly near root, scanty near intestinal 6. fat deposits: throughout mesentery
wall mesentery is opaque
‘clear windows’ in mesentery
7. no Peyer’s patches 7. aggregation of lymphoid tissue
Peyer’s patches present in mucous mbm found along
ant-mesenteric border
Blood Supply
• The blood supply is from the sup mesenteric artery, which is the art to the midgut
• Branches - sup mesenteric art lies btw the folds of the mesentery
- 15-20 jejunal & ileal branches arise from
its convex L side & runs towards the intestinal wall
• Arcades - each br divides into 2
unite with adj branches to from a series of arcades
- branches from the arcades divide & form a series of arcades
- less arcades in jejunum, more in ileum
- from the terminal arcades, small straight branches (vasa recta) runs
towards the intestinal wall & supply it
- longer, less freq terminal branches in jejunum
shorter, more numerous terminal branches in ileum
- lowest part of the ileum is also supplied by the ileocolic art
Venous Drainage
The veins correspond to the branches of the sup mesenteric art
They drain mainly into the sup mesenteric vein
Clinical Notes
1. Identification of jejunum & ileum very impt during surgery
Thus knowledge of differences essential
2. Thrombosis of sup mesenteric art will cut off bld supply to midgut ischemia
May result in death due to intestinal obstruction
46
Transverse Colon
The tnvs colon is part of the large intestine
Appearance
External • long muscle aggregated into 3 bands: taeniae coli
• the wall is sacculated ie haustrations
• finger-like evaginations of serous coat containing fat
appendices epiploicae
Internal • absence of mucosal folds (plicae circulares)
• absence of villi
• absence of Peyer’s patches
Mesentery
• well-defined mesentery = tnvs mesocolon
• attached to sup border of tnvs colon
• longest part in the middle, shortest part at the flexures
Thus flexures are relatively fixed whereas rest of tnvs colon are mobile
Flexures
L colic flexure • more acute
(splenic flexure) • at higher level than R colic flexure
• It is suspended from the diaphragm by phrenico-colic lig
R colic flexure • less acute
(hepatic flexure) • at lower level than L colic flexure
(because of greater size of R lobe of liver)
Relations
Anteriorly Posteriorly
1. greater omentum 1. 2nd part of duodenum
2. ant abd wall 2. head of pancreas
3. coils of jejunum & ileum
Clinical Notes
1. cancer of the colon
2. colostomy
ie. colon is brought to the surface through an incision of ant abd wall
Course
• runs downward & to the R bhd neck of pancreas
• in front of 3rd part of duod, L renal vein & uncinate process of pancreas
• enters root of mesentery before giving off its branches
• runs downward & to the R btw the layers of the mesentery
• ends by anastomosing with the ileal branch of its own ileocolic branch
Branches
inf pancreatico-duod art • passes to the R (can be single/double)
47
• along upper border of 3rd part of duod
• supplies pancreas & the part of duod after entry of bile duct
middle colic art • runs forward in tnvs mesocolon
• divides into L & R branches
• supplies tnvs colon
R colic art • passes to the R
• divides into asc & desc branches
• supplies asc colon
ileocolic art • passes downward & to the R
• gives off
1. sup branch : anastomose with R colic art
2. inf branch : anastomose with sup mesenteric art
: gives off ant & post cecal art
jejunal & ileal branches • 15-20 in number
• arise from L (convex) side of artery
• form arcades from which terminal straight branches arise to supply jejunum & ileum
Area of Supply
• The sup mesenteric art is the art of the midgut
• Thus its area of supply extends from the duod below the entry of the common bile duct to the proximal 2/3 of the tnvs
colon
Clinical Notes
1. occlusion of a series of branches results in poor nutrition of affected part of intestine
- no (rare) ischemia due to abundant anastomoses
2. occlusion of art will affect a large part of gut ischemia
death occurs due to intestinal obstruction
Portal Vein
• The portal vein is a valveless vein abt 8 cm long
• It drains bld from the GIT in the abd & most of the GIT in pelvis
• Is also receives bld from the pancreas & spleen & gallbladder
Origin
• formed by the union of the sup mesenteric vein & splenic vein
• bhd neck of pancreas at level of LV1
Course
• runs upward & to the R
• post to 1st part of duod
• reach free border of lesser omentum & enters hepatoduod lig
• lies in front of epiploic foramen
• asc to the porta hepatis, lying bhd hepatic art & bile duct
• breaks up into R & L terminal branches which lie bhd the corresponding branches of the hepatic art
• The portal vein is peculiar in that it behaves like an artery
ie breaks up into cap in the liver & unites again to form the hepatic veins
Tributaries
sup mesenteric vein • begins in R iliac fossa
• asc in the mesentery
• joins splenic vein portal vein
splenic vein • begins at hilum of spleen
• runs in lienorenal lig
• then runs bhd body of pancreas (lying below splenic artery)
• joins sup mesenteric vein portal vein
inf mesenteric vein • upward continuation of sup rectal vein
• asc lat to inf mesenteric art
• enters splenic vein just before formation of portal vein
does not drain directly into portal vein
Clinical Notes
1. wide angle of union btw sup mesenteric & splenic v
leads to streaming of bld flow in portal vein
ie R lobe of liver receives bld mainly from intestines
L lobe, caudate & quadrate lobes receive bld mainly from stomach & spleen
Thus, this is impt in the spread of infectious growths
2. portal hypertension causes bld to be diverted via the
portal-systemic anastomoses into systemic circulation
(may cause varicosities)
48
Portal-Systemic Anastomoses
• Under normal conditions,
portal venous bld liver IVC
• The portal-systemic anastomoses provide an alternative route for returning bld to the IVC should the above route be
blocked
Regions of Anastomoses
Regions Veins involved
lower 1/2 of esophagus 1. esophageal branches of L gastric vein (portal)
2. esophageal vein (systemic)
anal canal 1. sup rectal vein (portal)
2. middle & inf rectal veins (systemic)
paraumbilical region 1. paraumbilical veins in falciform lig (portal)
2. supf veins of ant abd wall (systemic)
retroperitoneal region 1. veins of asc & desc colon, duod, pancreas & liver (portal)
2. renal, lumbar & phrenic veins (systemic)
Clinical Notes
• Portal hypertension: bld diverted via these anastomoses to
systemic circulation & hence return to heart
• Portal-cava shunts
ie direct connection btw portal vein & IVC may be created to treat portal hypertension
Origin
• formed by the union of the cystic & common hepatic duct
• position of the jn is variable
Course
Its course can be divided into supraduod, retroduod & infraduod (pancreatic) parts
Supradoud Part • desc along R free margin of lesser omentum
• encircled by LN at its commencement
• relations: L = hepatic art
post = portal vein
epiploic foramen
IVC
Retroduod Part • desc bhd 1st part of duod
• relations: L = gastroduod art
post = portal vein & IVC
Infraduod Part • begins at upper limit of head of pancreas & desc bhd it
(Pancreatic Part) • terminates by piercing posteromed aspect of the middle of desc (2nd) part of duod
• at this pt usu joined by main pancreatic duct
• form an ampulla in duodenal wall = ampulla of Vater
• opens in duod by means of duodenal papilla
Note: the ampulla is surrounded by a sphincter = sphincter of Oddi
• relations: ant = head of pancreas
post = IVC
L = main pancreatic duct
R = 2nd part of duod
Nerve Supply
Symp & psymph fibres from hepatic plexus
Clinical Notes
• presence of gallstones blockage of bile duct (cholecystitis)
• This may lead to obstructive jaundice
Pancreas
• The pancreas is situated retroperitoneally in the epigastric & hypochondriac regions
• It extends from the concavity of the duod to the hilum of the spleen
ie. extends tnvsly
• It can be divided into a head, neck, body & tail
49
Relations
a) of the Head
- situated within concavity of duod
anteriorly 1. proximal end of tnvs colon
2. tnvs mesocolon
3. post wall of lesser sac
4. coils of jejunum
posteriorly 1. med border of R kidney
2. R renal vsls
3. IVC
4. termination of L renal vein
5. R crus of diaphragm
6. infraduod (pancreatic) part of common bile duct
- Uncinate process - extends from lower & L part of head
- projects upwards & to the L bhd sup mesenteric vsls
b) of the Neck
- joins the head to body of pancreas
anteriorly 1. covered with peritoneum
post wall of lesser sac
2. gastroduod art
3. sup pancreaticoduod art
posteriorly 1. sup mesenteric vein
2. splenic vein
3. these 2 veins join to form portal vein
c) of the Body
- has 3 surfaces
anteriorly 1. covered with peritoneum
post wall of lesser sac
2. stomach
The peritoneum on ant surface is continuous with asc layers of greater
omentum
posteriorly 1. splenic vein
2. aorta & origin of sup mesenteric art
3. L crus of diaphragm
4. L suprarenal gld
5. L kidney
6. L renal vsls
inferiorly 1. duodenojejunal flexures
2. coils of jejunum
superiorly projection (omental tuberosity)
d) of the Tail
- lies within lieno-renal lig
- closely related to splenic vsls
- in contact with hilum of inf part of gastric surface of spleen
Blood Supply
• branches from sup & inf pancreatico-duodenal arteries
• branches from splenic art
Lymphatic Drainage
head & body sup & inf pancreatic-duod nodes
celiac & sup mesenteric nodes
tail pancretico-lienal nodes (in hilum of spleen)
Clinical Notes
1. gld is deeply situated diagnosis of disease difficult
2. common site of cancer = head of pancreas
this may lead to obstruction of common bile duct obstructive jaundice
3. perforating ulcers of post gastric wall may penetrate the pancreas
cause leakage of digestive juices
Spleen
• The spleen is a lymphoid organ
• It functions as a site of immune response
as a filter ie remove old RBC
as a bld reservoir
Position
• It occupies the L hypochondium
• Its long axis follows the shaft of the 10th rib
• Extend forward fr scapular line to mid-axillary line
50
Relations
Anterior (Visceral) Surface The related viscera produce impressions on this surface
1. stomach
2. tail of pancreas
3. L colic flexure
4. L kidney
Posterior Surface 1. diaphragm
2. L pleura (L costodiaphragmatic recess)
3. L lung
4. 9th, 10th & 11th ribs
Peritoneum
spleen is surrounded by peritoneum
gastrosplenic lig • passes from hilus to fundus of stomach
• carry short gastric & L gastroepiploic vsls
lienorenal lig • passes from hilus to front of L kidney
• carry splenic vsls, tail of pancreas
Hilus of Spleen
transmits splenic vsls, lyphatics & autonomic nerves
Blood Supply
splenic art (branch of celiac trunk)
• runs along upper border of pancreas
• divides into 5 or 6 branches at hilus & enters the spleen
Venous Drainage
splenic vein
• leaves hilus & runs bhd body of pancreas
• joins sup mesenteric veins to form portal vein
Lymphatic Drainage
• emarge from hilus
• drain into pancreatico-duodenal nodes celiac nodes
Nerve Supply
• derived from celiac plexus ie ANS
• accompany splenic art & enters hilus
Clinical Notes
1. fracture of L lower ribs may result in ruptured spleen
2. infection enlargement of spleen
Suprarenal Glands
• These are yellowish retroperitoneal bodies lying on the upper poles of each kidney
• They are surrounded by renal fascia but are sep from kidneys by peri-renal fat
• They secrete hormones:
Part of Gland Hormones Secreted
Cortex 1. glucocorticoids
2. minerocorticoids
3. sex hormones
Medulla 1. adrenalin
2. noradrenalin
Relations
R Suprarenal L Suprarenal
Shape pyramindal semilunar
Anteriorly 1. IVC 1. postero-inf surface of stomach
2. bare area of liver 2. pancreas
3. post surface of R lobe of liver 3. splenic vsls
Posteriorly 1. diaphragm 1. L crus of diaphragm
2. kidney
Medially 1. R inf phrenic art 1. inf phrenic art
2. celiac ganglion 2. L gastric art
3. L celiac ganglion
Blood Supply
Artery Originate from
sup suprarenal art inf phrenic art
middle suprarenal art aorta
inf suprarenal art renal art
51
Venous Drainage
R suprarenal IVC
L suprarenal L renal vein
Lymphatic Drainage
into para-aortic nodes
Nerve Supply
• PreGN symp fibres from T8-T11, via greater & lesser splanchnic n
• No psymp supply
Clinical Notes
1. disease / atrophy insufficiency of mineralocorticoids & glucorticoids
results in Addison’s disease
2. hyperactiviy hermaphroditism
Cushing’s syndrome
Kidneys: Relations
• The kidneys are retroperitoneal
• They lie on either side of the vertebral bodies occupying the paravertebral gutters of the post abd wall
• The R kidney is lower than the L kidney
Right Kidney
Anterior from above downwards
Surface 1. R suprarenal gld
2. R lobe of liver
3. 2nd part of duodenum
4. hep flexure of colon
5. coils of small intestine
Area related to liver & small intestine covered by peritoneum
Posterior 1. the diaphragm sep upper pole from
Surface 2. pleura & costodiaphragmatic recess
3. 12th rib & last i/c space
4. med & lat arcuate lig
Below these, from med to lat
5. tips of tnvs processes of LV1 & LV2
6. psoas major
7. quaratus lumborum
8. tranversus abdominis
Intervening btw kidney & quadratus lumborum from above downwards
9. subcostal n
10. iliohypogastric n
11. ilioinguinal n
Left Kidney
Anterior 1. L suprarenal gld
Surface 2. spleen
3. post surface of stomach
4. body of pancreas
5. splenic vsls
6. splenic flexure of colon ie L colic flexure
7. coils of jejunum
8. L colic vsls
Area related to stomach, spleen, jejunum covered with peritoneum
The rest are devoid of peritoneum
Posterior the diaphragm sep upper pole from
Surface pleura & costodiaphragmatic recess
11th & 12th ribs & last i/c space
med & lat arcuate lig
Below these, from med & lat
tips of tnvs processes of LV1 & LV2
psoas major
quadratus lumborum
transversus abdominis
Intervening btw kidney & quadratus lumborum from above downwards
subcostal n
iliohypogastric n
ilioinguinal n
Ureter
The ureter is ∼ 25 cm. It is partly in the abd & partly in the pelvis
Throughout its course it is retroperitoneal
52
Origin
• begins as the renal pelvis
• at med border of kidneys
Constriction
1. at junction with renal pelvis
2. at brim of lesser pelvis (pelvic brim)
3. passage through bladder wall
Course
• passes downwards & medially
• runs on psoas major
• crosses in front of bifurcation of common iliac art
• enters pelvis
• runs downwards & backwards
• then opposite ischial spine it turns forward & medially
• reaches bladder obliquely
Relations of R Ureter
a) At Renal Pelvis
- branches of renal vsls lie both in front & bhd
- duod lies in front
- psoas major is posterior
b) Abdominal
anteriorly 1. 3rd part of duod
2. R colic vsls
3. ileocolic vsls
4. R gonadal vsls
5. root of mesentery
6. terminal part of ileum
posteriorly 1. psoas major
2. tips of lumbar tnvs processes
3. genitofemoral n
4. bifurcation of R common iliac artery
medially IVC
c) Pelvic Part
Female Male
posteriorly 1. int iliac art & vein 1. int iliac art & vein
2. lumbosacral trunk 2. lumbosacral trunk
3. sacroiliac jt 3. sacroiliac jt
laterally 1. fascia covering obt int 1. fascia covering obt int
2. branches of int iliac art 2. branches of int iliac art
It forms the post boundary of ovarian
fossa
As it turns forward towards 1. lies slightly above lat fornix of 1. ductus deferens crosses it sup from
the bladder vagina lat to med
2. uterine art crosses it from lat to 2. seminal vesicle lies below & bhd it
med side
d) Intravesical Part
- enters the bladder obliquely & acts as a valve to prevent backflow of urine
Relations of L Ureter
a) At Renal Pelvis
- branches of renal vsls lie both in front & bhd
- pancreas & coils of small intestine in front
- psoas major is posterior
b) Abdominal
anteriorly 1. L gonadal vsls
2. L colic vsls
3. sigmoid colon
4. sigmoid mesocolon
posteriorly 1. psoas major
2. tips of lumbar tnvs processes
3. genitofemoral n
4. bifurcation of L common iliac artery
medially inf mesenteric vsls
53
Blood Supply
1. renal art
2. aorta
3. common iliac art
4. vesical art
Venous Drainage
corresponds to bld supply
Lymphatic Drainage
part of the ureter drains into
upper 1/3 nodes around renal art
middle 1/3 common iliac nodes
lower 1/3 common, int & ext iliac nodes
Nerve Supply
• symp supply from T10 to L1
• via renal, hypogastric & pelvic plexuses
Clinical Notes
1. renal stones may cause obstruction of ureter
most common sites of lodging of stones are at the constrictions
2. renal colic: referred pain which passes from loin to groin
ie T11 to L2 segments
Course
• asc in front of lower LV
• on R side of abd aorta
• in front of R crus of diaphragm & R suprarenal gld
• enters thorax via caval opeing in diaphragm at level of TV8
• pierces pericardium
• opens into RA
Relations
anteriorly 1. root of mesentery
2. R gonadal art
3. duodenum & pancreas
4. portal vein & liver
posteriorly 1. R symp trunk
2. R crus of diaphragm
3. R suprarenal gld
4. R celiac ganglion
Tributaries
1. common iliac veins (L & R)
2. lumbar veins
3. L & R renal veins
4. hepatic veins
5. R gonadal vein
6. R suprarenal vein (L veins empty into L renal vein IVC)
7. R inf phrenic vein
Clinical Notes
occlusion of IVC bld will still reach RA via porto-systemic anastomoses
54
• desc into pelvis med to lumbosacral trunk & bhd common iliac vsls
Ganglia
• possess 4 segmentally arranged ganglia
• 1st & 2nd often fused together
• they (1st & 2nd) also receive WRC from L1 & L2
Branches
1. GRC - to the lumbar spinal n
- distributed to arrector pili muscles, BV & sweat glds of skin
2. fibres to symp plexuses on abd aorta & its branches
eg celiac plexuses, sup & inf mesenteric plexuses
3. fibres which pass down into pelvis to hypogastric plexus
Clinical Notes
lumbar sympathectomy produces cutaneous vasodilation
55
Pelvis
Pelvic Brim
• This is the inlet of the true pelvis
ie above the inlet is the greater / false pelvis
while below it is the lesser true pelvis
• It is oriented at an oblique plane
∼50° to 60° to the horizontal
Boundaries
anteriorly upper margin of pubic symphysis
posteriorly sacral promontory
either side linea terminalis, which includes ant margin of ala of sacrum, iliopectinal line, pectineal line,
pubic tubercle & pubic crest
Shape
In males: heart-shaped, widest towards the back
In female: transversely oval, widest further forward
Indentation by the promontory is more marked in males than in females
Relations
• At the Sacral Promontory
median plane median sacral art
medially hypogastric plexus
laterally pelvic symp trunk & ganglia
• At the Ala of the Sacrum
from med to lat are: 1. lumbosacral trunk
2. iliolumbar artery
3. obturator n running towards obturator foramen
4. on L side sup rectal artery
• At Sacroiliac Joint
- 1. bifurcation of common iliac vsls into int & ext iliac vsls
- int iliac vsls: cross pelvic brim to enter pelvis
- ext iliac vsls: related along outer edge of pelvic brim
2. ureter passes into pelvic cavity lying on the bifurcation
- on L side: med limb of pelvic mesocolon
• At Iliopectinal Line
- 1. ovary lies just below pelvic brim in front of ureter
2. psoas major
3. ext iliac, genitofemoral & gonadal vsls
- In female: the uterine artery crosses the iliopectineal line
to enter the broad lig
- more anteriorly, vas deferens (in male)
round lig of uterus (in female)
• At Pectineal Line
1. attached is pectineal lig laterally
lacunar lig medially
2. conjoint tendon deep to lacunar lig
3. femoral ring is lat to lacunar lig
4. pubic branch of inf epigastric artery crosses lat margin of lacunar lig
• At Pubic Tubercle
- attached is med end of ing lig
- in male: crossed by spermatic cord
• At Pubic Crest
1. attached is the rectus abdominis
2. bladder is posterior
Pelvic Diaphragm
• This includes the levator ani & coccygeus
• The pelvic diaphragm sep the pelvis from the perineum
• The muscle fibres slope backward & downwards to the midline making a gutter-shaped pelvic floor
Levator Ani
• This is composed of
1 levator prostate in male sling around prostate / vagina
pubovaginalis in female & inserted into perineal body
2 puborectalis sling around jn of rectum & anal canal
3 pubococcygeus inserted into anococcygeal body & coccyx
4 iliococcygeus inserted into anococcygeal body & coccyx
Origin • from the white line (thickening of pelvic fascia over obt int)
• stretched from post surface of body of pubis to ischial spine
Insertion • surround prostate / vagina & inserted into perineal body
56
• surround rectum
• also inserted into anococcygeal body & tip of coccyx
Nerve Supply 1. branch from S4
2. branch from pudental n
Coccygeus
Origin • from ischial spine
• sacrotuberous lig
Insertion • SV5
• anococcygeal body & coccyx
Nerve Supply branches from S4 & S5
Contents in Male
1. crura of the penis covered medially by the ischiocavernosus muscles
2. bulb of the penis containing proximal part of penile urethra
covered by bulbospongiosus muscles
3. supf tnvs perinea muscles
4. perineal body - attached to centre of post margin of UG diaphragm
- provide attachment for 1. ext anal sphincter
2. bulbospongiosus
3. supf tnvs perinea
5. perineal branch of pudendal n
Muscles in Male
Ischiocavernosus Bulbospongiosus Supf Tnvs Perinei
Origin ischial tuberosity perineal body ischial ramus
Insertion fascia covering corpus 1. fascia of bulb of penis perineal body
cavernosum 2. corpus spongiosum & cavernosum
Nerve Supply perineal br of pud n perineal br of pud n perineal br of pud n
Actions assist erection of penis compress urethra & assist in erection fix perineal body & help suppor
of penis pelvic viscera
Contents in Female
1. crura of clitoris covered medially by ischiocavernosus muscles
2. bulbs of the vestibule covered by bulbospongiosus muscles
3. supf tnvs perineal muscles
4. perineal body - situated btw vagina & anal canal
- provide attachment for perineal muscles
- more impt than in male because it
indirectly supports wt of pelvic viscera esp uterus
5. perineal branch of pudendal n
57
Muscles in Female
Ischiocavernosus Bulbospongiosus Supf Tnvs Perinei
Origin ischial tuberosity perineal body ischial ramus
Insertion fascia covering corpus fascia covering corpora cavernosum perineal body
cavernosum of clitoris
Nerve Supply perineal br of pud n perineal br of pud n perineal br of pud n
Actions assist erection of clitoris 1. sphincter of vagina fix perineal body & help suppor
2. assist erection of clitoris pelvic viscera
Clinical Notes
• In males
- during straddle-type accidents, urethra is damaged
urine leaks into supf perineal pouch
& subseq inflammation causes swelling at level of ischial tuberosity
• In females
- damage to perineal body, esp during parturition
may result in permanent weakness of pelvic floor
(& prolapse of uterus)
Contents in Male
1. sphincter urethrae muscle
2. deep tnvs perinei muscles
3. membranous urethra
4. bulbo-urethral (Cowper’s) glds - 2 small glands
- embedded in sphincter urethrae
- its ducts pierce inf fascia of UG diaphragm &
enter penile urethra
5. inf pudendal art – gives rise to 1. art to bulb of penis
2. art to crura of penis
3. dorsal art of penis
6. dorsal n of penis
Muscles in Male
sphincter urethrae deep tnvs perinea
origin pubic arch ischial ramus
insertion surrounds urethra perineal body
nerve supply perineal br of pud n perineal br of pud n
actions voluntary sphincter of urethra fixes perineal body
Contents in Female
1. sphincter urethrae muscle
2. deep tnvs perinei muscles
3. part of vagina – pierce sphincter urethrae
4. membranous part of urethra – pierce sphincter urethrae
5. int pudendal art – gives branches to the clitoris
6. dorsal n to clitoris
Muscles in Female
1. Sphincter urethrae – same as for male
2. Deep tnvs perinea – same as for male
Clinical Notes
rupture of membranous part of urethra
urine escapes into deep perineal pouch
58
Ischiorectal Fossa
It is a wedge-shaped space on each side of the anal canal
Boundaries
Base skin & fascia
Apex meeting of med & lat walls
Medial Wall 1. levator ani with anal fascia superiorly
2. ext anal sphincter with fascia inferiorly
Lateral Wall is vertical
1. obt int with fascia & obt foramen
2. med surface of ischial tuberosity below attachment of obt
fascia
Anteriorly post border of perineal mbm & body of pubis
Posteriorly 1. gluteus maximus
2. sacrotuberous lig
Recesses
ant recess proceeds forward above UG diaphragm till limited by anal fascia
post recess deep to sacrotuberous lig
horse-shoe recess connects the 2 fossae bhd to anal canal
Contents
1. ischiorectal pad of fat
2. pudendal canal with its contents (pudendal n & int pudendal vsls)
lies along lat wall of fossa
3. inf rectal n & vsls arch downward from lat to med
4. perineal br of S4 n
5. post scrotal n & vsls
6. perforating cutaneous branches of S2 & S3 n
Clinical Notes
1. allow distension of rectum & anal canal during passage of feces
2. common sites of absecesses
3. fat acts as support for rectum
Thus disease causes prolapse of rectum
4. poorly vasculated infections are diff to clear with antibiotics
5. pudendal n may be blocked by anaesthetic during forceps delivery
59
Thus, it presents 2 deficiencies (1 on each side) which allows communication with ext envt
The ovarian fossa is formed btw elevation produced by the obliterated umb art & the ureter posteriorly
It lies on the lat pelvic wall & has the ovary resting within its boundaries
Clinical Notes
1. hysterosalpingography
- radioactive material is injected into uterus
If uterine tubes are patent, readioactivity will spill into peritoneal cavity
via deficiencies in peritoneum
2. access to peritoneal cavity is via post wall of vagina & hence rectouterine pouch (of Douglas)
insertion of scaples
extraction of ova for in-vitro fertilisation
Rectum
The rectum is abt 12 cm long
Flexures
Flexures Remarks
3 lat uppermost & lowermost flexures directed to the R
2 anteropost • the first follows curvature of sacrum = sacral flexure
• the 2nd located at jn of rectum & anal canal = perineal flexure
(perineal flexure is maintained by puborectalis sling)
External Apperance
The rectum can be distinguished by
1. absence of mesentery & appendices epiploicae
2. absence of haustra
3. teniae coli to form longitudinal muscle coat
Peritoneum
upper 1/3 peritoneum covers ant & lat surfaces
middle 1/3 peritoneum covers ant surface only
lower 1/3 uncovered
Relations
Ant In the male, In the female,
upper 2/3 (covered by peritoneum) upper 2/3 (covered by peritoneum)
is related to: is related to:
1. sigmoid colon 1. sigmoid colon
60
2. coils of ileum occupying rectovesical 2. coils of ileum occupying rectouterine pouch
pouch lower 1/3 (devoid of peritoneum)
lower 1/3 (devoid of peritoneum) is related to:
is related to: 3. post wall of vagina
3. post surface of bladder Note: rectouterine pouch sep rectum fr
4. termination of vas deferens 1. lower part of uterus
5. seminal vesicles 2. upper part of vagina
6. prostate
Post 1. sacrum
2. piriformis
3. levator ani & coccygeus
4. sacral plexus & symph trunks
5. median sacral vsls
Lat 1. lat lig of rectum
In females, also uterosacral folds & lig
Blood Supply
Artery Remarks
1 sup rectal art supplies mucosa
2 middle rectal art supplies muscular coat
3 inf rectal art anastomose with sup rectal art
4 median sacral art supplies dilated lower part of rectum (ampulla)
Venous Drainage
• follow arteries
• however free anastomosis exist btw the sup, middle & inf rectal veins
porto-systemic anastomosis
Lymphatic Drainage
into pararectal nodes into 1. inf mesenteric nodes
2. int iliac nodes
Nerve Supply
• inf hypogastric plexus
• symp from L1, L2
psymp from S2-S4
Clinical Notes
1. partial & complete prolapses of the rectum through the anus
2. varicosities of the rectal veins = hemorrhoids (piles)
Anal Canal
The anal canal is about 1 1/2 inches long
Relations
Anteriorly In the male, In the female
1. perineal body 1. perineal body
2. UG diaphragm 2. UG diaphragm
3. membranous part of urethra 3. lower part of vagina
4. bulb of penis
Posteriorly anoccoygeal body, which sep it from the coccyx
Laterally ischiorectal fossae containing fat, etc
Sphincters
int anal sphincter • continuation of circular SM fibres of the rectum
• encircles upper 3/4 of anal canal
• involuntary
ext anal sphincter • composed of striated muscle
• voluntary
• consist of 3 parts
1. deep part
2. supf part
3. subcut part
The puborectalis part of levator ani blends with deep part of ext anal sphincter to form a sling
cause rectum to join to anal canal at an angle
61
Internal Apperance
Upper Part of Anal Canal • derived from hindgut endoderm
• lined by columnar epithelium
• mucosa thrown into vertical folds called anal columns
joined at their lower ends by
small semilunar folds called anal valves
• The upper part is sep from the lower part by the pectinate line (Hilton’s white
line)
Lower Part of Anal Canal • derived from ectoderm
• lined by str sq epithelium
• no anal columns
Clinical Notes
1. hemorrhoids - int (from sup rectal vein & tributaries)
ext (from inf rectal vein & tributaries)
2. per rectal examination
Urinary Bladder
• The bladder serves as a reservoir for urine
• It is the most anterior organ within the pelvic cavity &
lies immediately bhd the symphysis pubis, sep from it by the retropubic space
Peritoneum
sup surface & upper part of post surface covered by peritoneum
Inferior of Bladder
• in an empty bladder, the greater part of mucosa shows irregular folds
due to its loose attachment to the muscular coat
• The only smooth part is the trigone, which has the following boundaries:
62
superiorly interureteric ridge connecting ureteric openings
on each side line connecting each ureteric opening to int urethral opening below
Blood Supply
from sup & inf vesical art
• base is supplied by: art of ductus deferens in male
vaginal art in female
Venous Drainage
• via vesical venous plexus
• drains into into iliac vein
Lymphatic Drainage
• mainly to ext iliac nodes
• base drains into int iliac nodes
Nerve Supply
• vesical & prostatic plexuses
• symp fibres from T10-L2
psymp from pelvic splanchnic n (S2-S4)
Clinical Notes
1. a full bladder may rise into the abd cavity
may be ruptured by a blow to lower part of abd
2. rupture leads to leakage of urine into extraperitoneal space
3. bimanual palpation of the bladder
Prostate Gland
• The prostate is shaped like an inverted pyramid, located in pelvis
• It is a fibromuscular & glandular organ that surrounds the prostatic urethra
• Dimensions: base = 4 X 2 cm
height = 3 cm
• It lies btw the neck of bladder (above) & UG diaphragm (below)
• It is an accessory gld in the male
Functions
• production of a thin, milky fluid containing citric acid & acid phosphatase
• added to semial fluid at ejaculation
Capsule
• prostate is surrounded by fibrous capsule
• outside capsule is a fibrous sheath (which is part of visceral layer of pelvic fascia)
• the fibrous sheath contains the prostatic venous plexus
Surfaces
The prostate has a base, apex & 4 surfaces
ant, post, & 2 lat
Lobes
It is completely divided into 5 lobes
ant lobe • lies in front of urethra
• devoid of glds
median lobe • wedge-shaped
• lies btw upper part of urethra & ejaculatory duct
• related to trigone of bladder
• rich is glds
post lobe • bhd urethra, below ejaculatory duct
• contains glandular tissue
L & R lat lobes • lie on either side of urethra
• sep by shallow vertical groove on post surface of prostate
• rich in glds
Relations
Superiorly neck of bladder
Inferiorly UG diaphragm
63
Anteriorly 1. pubic symphysis, sep by retropubic space containing fat
2. puboprostatic lig connect fibrous sheath to post surface of pubic bones
Posteriorly rectal ampulla, sep by rectovesical septum
Laterally ant fibres of lev ani
Blood Supply
1. inf vesical art – br of int iliac art
2. middle rectal art – br of ant trunk of int iliac art
These form an outer subcapsular plexus & an inner periurethral plexus
Venous Drainage
• the veins form the prostatic venous plexus around the prostate btw the capsule & fibrous sheath
• drain into int iliac veins
Lymphatic Drainage
mainly to int iliac nodes & sacral nodes
Nerve Supply
• prostatic plexus of n
• derived from lower part of inf hypogastric plexus
Clinical Notes
1. carcinoma of prostate
2. senile enlargement
Seminal Vesicles
• These are 2 lobulated sacs lying on post surface of bladder
• Each is abt 5 cm long & fusiform in shape.
• They are directed upwards & laterally upper ends are widely sep
while their lower ends are close tog
Relations
Medially terminal part of vas deferens
Posteriorly rectum
Inferiorly • each seminal vesicle narrows & joins the vas deferens to form the ejaculatory ducts
• the 2 ducts run through the substance of the prostate to open into the prostatic urethra, lat of opening
of prostatic utricle
Blood Supply
art of the ductus deferens
Venous Drainage
into prostatic & vesical venous plexus
Lymphatic Drainage
ext & int iliac nodes
Nerve Supply
• inf hypogastric & prostatic plexus
• symp supply from T11-L1
psymp supply from S2-S4
Ovary
• The ovary is the germinal & endocrine gld of the female
• It is diamond-shaped
• Dimensions: 3 X 2 X 1 cm
Parts of Ovary
It has lat & med surfaces
upper (tubal) & lower (uterine) poles
ant (mesovarian) & post (free) borders
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Relations
Anteriorly obliterated umbilical art
Posteriorly 1. ureter
2. int iliac art
The obt n crosses floor of ovarian fossa
Posterolat frimbrae of infundibulum of fallopian tube
Fixation
suspensory lig
• peritoneal fold running from its upper extremity to the iliac vsls
• btw attachment of mesovarium & lat wall of pelvis
• carries ovarian vsls, n & lymphatics
round lig of ovary • from upper end to lat wall of uterus to med margin of ovary
• remains of upper part of gubenaculum
(round lig of uterus if remains of lower part)
mesovarium • joins ant border to post side of broad lig
• transmits vsls & n
Blood Supply
ovarian artery - branch of aorta at LV1 level
- desc in suspensory lig to broad hg
- sends branches to ovary & uterine tubes
- anastomose with uterine art
Venous Drainage
pampiniform plexus ovarian vein R side into a IVC
L side into L renal vein
Nerve Supply
ovarian plexus (derived from renal, aortic & hypogastric plexuses)
- accompany ovarian art
- contains symp n (T10, 11)
psymp n (S2, 3, 4)
Thus pain is referred to ing & vulval regions
Lymphatic Drainage
1. pre-aortic nodes
2. para-aortic nodes
Clinical Notes
Before puberty, ovary is smooth & grayish pink
After puberty, it is puckered & turns gray
When old, it may shrivel
1. ovarian cysts
2. ovarian carcinomas
3. prolapse of ovaries into rectouterine pouch
Uterus
The uterus is the child-bearing organ in the female
Position (Location)
• btw bladder & rectum
• within broad hg
• lower end forms an approx right angle with vagina
angle of anteversion
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• covered with peritoneum
which is reflected onto bladder forming uterovesical pouch
Intestinal
Surface
• related to sigmoid colon & coils of small intestines
• covered with peritoneum
Lateral Margins
• receives uterine tubes, uterine vsls by the side
• related to broad lig (mesometrium)
• round lig & lig to ovary attached here
- Cavity of body is triangular in coronal section
but merely a cleft in sagittal section
3. Isthmus
- constricted part of uterus ∼ 1 cm in length
- cavity called int os
4. Cervix
- extends downwards & backwards from isthmus
- pierces ant wall of vagina
- divided into supravaginal & vaginal parts
supravaginal part anteriorly: bladder
posteriorly: coils of small intestine
laterally: uterine art & ureter embedded in parametrium
vaginal part protudes into vagina forms vaginal fornix
- The cavity of the cervix, the cervical canal, is spindle-shaped &
communicates with cavity of body through internal os,
& with the vagina through the external os
Peritoneum
• from middle 1/3 of rectum, peritoneum reflected
onto post surface of upper part of vagina
rectouterine pouch (of Douglas)
• continues over intestinal surface of uterus (body)
• passes round fundus
• continues down over vesical surface of body
• at level of fornix (ant) of vagina
peritoneum reflected onto post surface of bladder
Blood Supply
1. uterine art - br of int iliac art
2. ovarian art (partly) - br of aorta arising from LV1 level
Venous Drainage
• venous plexus drains through uterine, ovarian & vaginal veins
• into int iliac vein
Lymphatic Drainage
• fundus into para-aortic nodes
• body & cervix into int & ext iliac nodes
Note: a few lymph vsls also drain into supf ing nodes
Nerve Supply
• uterovaginal portions of inf hypogastric plexus
• Symp supply from Tl2, L1
Psymp supply from S2-S4
Clinical Notes
1. uterine examination by bimanual palpation
2. prolapse of uterus
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3. fascial condensations (ligs) & possibly
4. peritoneal folds
Clinical Notes
• tear of the perineum may cause a prolapse of the uterus
• also due to hard labour or weakness in any of the supports
Location
at upper free border of broad lig (mesosalpinx)
67
Parts
1 infundibulum
• lat expanded part with abd ostium (opening)
surrounded by finger-like fimbrae
• one fimbra = ovarian fimbra attaches it to tubal pole of ovary
• inner surface lined by ciliated columnar epithelium
2 ampulla
• med continuation of infundibulum
• thin walled & dilated
• follows a tortuous course, arching over ovary
3 isthmus
• constricted part med to ampulla
• has thicker walls than ampulla
4 intramural
• lies within uterine wall
• opens into uterus at sup angles of uterine cavity
by a narrow uterine ostium
Blood Supply
med 2/3 uterine art (br of int iliac)
lat 1/3 ovarian art (from abd aorta)
Venous Drainage
veins drain into 1.pampiniform plexus of ovary
2. uterine veins
Lymphatic Drainage
• most drain into lat aortic & pre-aortic nodes
• some (around isthmus) follows round lig of uterus into supf ing nodes
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Nerve Supply
symp T10-L2
via inf hypogastric plexus
psymp mainly from pelvic splanchnic n (S2-4)
via inf hypogastric plexus
Clinical Notes
1. tubal pregnancy common ectopic pregnancy
2. sterility caused by blockage of tube (due to inflammation)
3. female sterilization by tubectomy
ligated & excised
Vagina
• The vagina is the female copulatory organ
• It extends upward & backward from vulva to uterus
& is situated bhd to the bladder & urethra
in front of recturn & anal canal
• It measures abt 8 cm long & has ant & post walls
which are normally in apposition
• In the virgin, lower end of vagina is partially closed by hymen (mucous mbm).
After rupture, a round elevation called carunculae hymenale is formed
• At upper end, ant wall is pierced by the cervix
lumen there is circular & can be divided into 4 fornices
ie. ant, post, R lat & L lat
The ant fornix is shallowest while post fornix is deepest
Relations
Anteriorly upper 1/2: base of bladder
lower 1/2: urethra
Posteriorly upper 1/3: Douglas pouch + loops of ileum & sigmoid colon
middle 1/3: ampulla of rectum
lower 1/3: anal canal & perineal body
Laterally upper 1/3: 1) tnvs cervical lig
in which are embedded the network of vaginal veins
2) ureter, which is crossed by uterine art
middle 1/3: pubococcygeus (part of lev ani)
lower 1/3: pierces UG diaphragm
related to bulb of vestibule
bulbospongiosus
greater vestibular glds (of Bartholini)
Blood Supply
• mainly by vaginal branch of int iliac art
• also by uterine, middle rectal & int pudendal art
• Anastomosis of these forms the vaginal azygos arteries
in the midline a anteriorly & posteriorly
Venous Drainage
rich venous plexus vaginal vein int iliac vein
Lymphatic Drainage
upper 1/3 ext iliac nodes
middle 1/3 int iliac nodes
lower 1/3 med group of supf ing nodes
Nerve Supply
lower 1/3
• pain sensitive
• supplied by 1) inf rectal n (from pudendal n)
2) dorsal labial branches of perineal n
upper 2/3
• pain insensitive
• by symp L1, L2
psymp S2, 3, 4
Supports of Vagina
upper : levator ani
: tnvs cervical, pubocervical & sacrocervical lig
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middle : UG diaphragm
lower : perineal body
Clinical Notes
1. prolapse of vagina
2. vaginal lacerations
3. vaginitis
4. vaginal examinations
Origin
• continuation of tail of epididymis
• tortuous, but gradually straightens out
Blood Supply
1. artery of ductus deferens (br of inf vesical art)
2. inf vesical & middle rectal arteries
Venous Drainage
via prostatic & vesical plexuses int iliac veins
Lymphatic Drainage
into ext iliac nodes
Nerve Supply
autonomic fibres from sup & inf hypogastric plexuses
Clinical Notes
vasectomy = sterilization of the male
ligation of ductus deferens
70
Male Urethra
• The male urethra is abt 20 cm in length
• It begins at the neck of the bladder & extends through the prostate, pelvic diaphragm, sphincter urethrae, root & body of
penis, to the tip of the glans
ends at ext urethral orifice
Clinical Notes
1. rupture of urethra
- at jn of prostatic & membranous parts
urine leaks into extraperitoneal space around bladder
- membranous part
urine leaks into supf perineal space
may spread into penis, scrotum & front of abd
2. examination: by passing a catheter through it
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Pudendal Nerve
Origin
• branch of sacral plexus
• S2, 3, 4 (ant rami)
Course
• leaves pelvis via greater sciatic foramen, below piriformis
• enters gluteal region
• crosses back of ischial spine, where it is med to int pudendal art
• enters perineum through lesser sciatic foramen
• enters pudendal canal in lat wall of ischiorectal fossa
• gives oft first: 1) inf rectal n
then 2) perineal n
ends as: 3) dorsal n of penis I clitoris
Branches
1 inf rectal n
• runs medially across ischiorectal fossa in company with corresponding vsls
• supplies 1. ext anal sphincter
2. mucous mbm of lower 1/2 of anal canal &
3. perianal skin
2 perineal n supplies 1. muscles of UG triangle
2. skin on post surface of scrotum / labia majora
3 dorsal n of penis / distributed to penis / clitoris
clitoris
Clinical Notes
• can be blocked either through vagina or from perineum
area supplied by pudendal n is anaesthetized
Note: the pudendal n is the principal n supply of the perineum
Lumbar Plexus
• formed in the psoas muscle
• from the ant rami of L1-L4 n
• Ant rami receive GRC from symp trunk
• LI & L2 give off WRC to the symp trunk
• branches emerge from the lat and med borders of the muscle
and from its ant surface
Branches
1. iliohypogastric
2. ilioinguinal
3. genitofemoral
4. lat femoral cut n of thigh
5. femoral n
6. obt n
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• enters thigh bhd the ing lig and lat to
femoral sheath
73
Lower Limb
Venous Drainage of Lower Limb
The veins of the lower limb can be divided into 2 groups
supf under the skin in supf fascia
deep accompany art deep to deep fascia
Both sets provided with valves (more numerous in deep veins)
Superficial Veins
• bld from the foot drains into 1) dorsal digital veins
2) communicating veins from sole
3) metatarsal veins
4) med & lat marginal veins
• metatarsal veins from dorsal venous arch
• medially: arch gives rise to great saphenous vein
laterally: arch gives rise to small saphenous vein
Deep Veins
• arise from venae comitantes that accompany the main arteries of the leg & foot
• possess numerous valves
• communicate with the supf veins via perforating veins
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Mechanism of Venous Return
1. calf muscles pump (esp for deep veins)
2. valves - prevent backflow
Clinical Notes
1. coronary bypass surgery: great saphenous vein used to replace coronary art
2. varicose veins (esp supf veins) due to deep venous thrombosis
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Lymphatic Drainage
• Most of the lymph passes through a terminal group of lymph nodes
supf & deep ing nodes
• Before reaching these nodes,
they may pass through a series of outlying, intermediary nodes
Lymph Nodes
1. Superficial Inguinal Lymph Nodes
- arranged in horiz & vertical rows
Horiz Row
• chain of 5-6 nodes found in supf fascia below ing lig
• lat members drain gluteal region
& ant abd wall below umb
• med members drain ext genitalia (except glans penis)
lower part of anal canal & peri-anal region
Vertical Row
• 4-5 nodes along terminal part of great saphenous vein
• receive all supf lymph vsls of lower limb
except area drained by small saphenous vein
- The supf ing nodes drain into the ext iliac nodes
2. Deep Inguinal Lymph Nodes
- vary from 1-3
- situated on med side of femoral vein
- receive lymph from 1. deep lymph vsls accompanying femoral vsls
2. glans penis / clitoris
- they drain into ext itlac nodes
3. Outlying Intermediate Lymph Nodes
- are few in no. & deeply placed
- the impt ones are
Anterior Tibial only 1
Node found at upper end of ant tibial vsls adjoining interosseous mbm
Popliteal
Lymph Nodes
• 6-7 in no.
• situated along popliteal vsls in popliteal fossa
• drains 1) area drained by small saphenous vein
2) knee jt
3) lymph vsls accompanying ant & post tibial vsls
- they drain into supf & deep ing nodes
Lymph Vessels
1. Superficial Vessels
- begins in lymphatic plexuses beneath skin
- divided into med & lat groups
med gp
• begin on tibial side of dorsum of foot
• accompany great saphenous vein
• end in vertical row of supf ing LN
lat gp
• begin on fibular side of dorsum of foot
• some cross front of leg to join med gp
• others accompany small saphenous vein & end in popliteal nodes
- supf vsls of buttock terminate in horizontal row of supf ing nodes
2. Deep Vessels
- accompany the main BV
ant & post tibial nodes
peroneal nodes
popliteal nodes
femoral groups end in corresponding nodes
- deep vsls of gluteal & ischial regions follow corresponding BV & most end in int iliac nodes
Clinical Notes
1. enlargement of supf ing nodes due to disease in their area of drainage
eg. scrotal carcinoma
abscess in perineum & anal canal
2. lesion of lat side of heel inflammation of popliteal nodes
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Hip Joint
Type
synovial ball & socket jt
Articulation
1. head of femur
2. acetabulum of hip bone
- articular surface of acetabulum deficient inferiorly acetabular notch
- cavity of acetabulum deepened by presence of fibrocartilaginous rim
acetabular labrum
Capsule
• encloses jt
• medially: attached to acetabular labrum
laterally: attached to intertrochanteric line & post aspect of neck of femur
• anteriorly part of capsule reflects back towards the head as the retinacula
convey bld supply to head & neck of femur
Ligaments
1 iliofemoral lig
• strong & Y-shaped
• from ant inf iliac spine to intertrochanteric line
• prevents overextension during standing
2 ischiofemoral lig
• spiral in shape
• from body of ischium to greater trochanter
• limits extension
3 pubofemoral lig
• triangular in shape
• from sup ramus of pubis to intertrochanteric line
• limits extension & abduction
4 tnvs acetabular lig
• formed by acetabular labrum
• bridges acetabular notch
5 lig of head of femur
• from tnvs lig to fovea capitis
Synovial Membrane
• lines capsule
• attached to margins of articular surfaces
• forms a bursa: psoas bursa beneath psoas tendon
Nerve Supply
1. femoral n (via branch to rectus femoris)
2. obturator & sciatic n
3. n to quadratus femoris
Blood Supply
1. sup & inf gluteal art
2. circumflex femoral & obturator arteries
These form trochanteric anastomosis to supply the jt
Movements
• wide range of movements, but less than shoulder jt
• some of the movement sacrificed for stability
movements muscles responsible
1 flexion 1. iliopsoas
2. rectus femoris
3. sartorius
4. adductor muscles
2 extension 1. gluteus maximus
2. hamstrings
3 abduction gluteus medius & minimus
4 adduction 1. adductor longus & brevis
2. adductor fibres of adductor magnus
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5 lat rotation 1. piriformis
2. obturator int & ext
3. quadratus femoris
6 med rotation 1. ant fibers of gluteus medius & minimus
2. tensor fasciae lata
7 circumduction combination of the above movements
Relations
Anteriorly 1. iliopsoas
2. pectineus
3. rectus femoris
These sep the jt from femoral vsls & n
Posteriorly 1. obturator internus
2. gemelli
3. quadratus femoris
These sep the jt from sciatic n
Superiorly 1. piriformis
2. gluteus minimus
Inferiorly obturator ext tendon
Stability
• relatively stable jt
• stability maintained by several factors
1 bony factors
• acetabulum is deep
• additional depth provided by acetabular labrum
provide snug fit for head of femur
2 capsule encloses jt
strong anteropost, thin & loosely attached posteroinf
3 ligaments 1. iliofemoral
2. ischiofemoral
3. pubofemoral
4 muscles
• anteriorly - iliopsoas
- rectus femoris
• anterolat - gluteus medius
- gluteus minimus
• posteriorly - piriformis
- obturator internus
- gemelli
- quadratus femoris
covered by gluteus maximus
• posteroinf - obturator externus
5 synovial fluid provides strong cohesive force
Clinical Notes
1. jt disease: osteoarthritis (arthrosis)
2. post dislocation involves sciatic n
Knee Joint
The knee it consist of 3 jts: 2 condylar jts & 1 gliding jt
Type
• the 2 condylar jts are synovial hinge jts (with some rotatory movement)
• the gliding jt is of the plane variety
Articulation
articulation type of jts
1 btw med condyles of femur & tibia condylar jt
2 btw lat condyles of femur & tibia condylar jt
3 btw patella & lower end of femur gliding jt
The articular surfaces are covered with hyaline cartilage
Capsule
• fibrous capsule
• surround sides & post aspects of jt, absent anteriorly
• attachments
79
attached to remarks
superiorly femur
• articular margins of condyles
• intercondylar line posteriory
• deficient on lat condyle due to passage of popliteus tendon
inferiorly tibia
• articular margins of condyles, except at lat condyle to allow passage
of popliteus tendon
• prolonged inferolat over popliteus to head of fibula
arcuate popliteal lig
Ligaments
1. Extracapsular
ligamentum patallae
• continuation of quadriceps femoris
• sep from synovial mbm by infrapatellar pad of fat
• sep from tibia by deep infrapatellar bursa
• attachments
sup lower border of patella
inf tubercle of tibia
lat collat lig
• sep from lat meniscus by popliteus tendon
• splits biceps femoris tendon into 2 parts
• attachments
sup lat condyle of femur
inf head of fibula
med collat lig
• attachments
sup med condyle of femur
inf med surface of shaft of tibia
Note: attached to edge of med meniscus & fibrous capsule
oblique popliteal lig
• derived from semimembranosus tendon
• strengthens post aspect of capsule
• arises post to med condyle of tibia, passes superolat
& attached to central part of post aspect of capsule
arcuate popliteal lig
• strengthens post aspect of capsule
• arises from capsule
2. Intracapsular
ant cruciate lig
• extends superiorly, posteriorly & laterally
• attachments
sup post part of med surface of lat femoral condyle
inf ant intercondylar area of tibia
• functions 1) prevent post displacement of femur on tibia
2) prevent hyper-extension of knee it.
post cruciate lig
• extends superiorly, anteriorly & medially
• attachments
sup ant part of lat surface of med femoral condyle
inf post intercondylar area
• functions 1) prevent ant displacement of femur on tibia
2) prevent hyperflexjon of_knee jt
Menisci
• C-shaped rings of fibrocartilage
called semi-lunar cartilages
• lie on articular surface of tibia
• consist of med & lat semilunar cartilages
• attachments
ant horn ant intercondylar area
post horn post intercondylar area
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peripheral margins fibrous capsule of knee jt
• functions 1) deepen articular surfaces of tibia
2) lubrication & shock absorption
Synovial Membrane
• lines inner aspect of capsule
• attachments 1) margins of articular surfaces
2) peripheral edges of menisci
• folds
anteriorly infrapatella & alar folds
posteriorly around cruciate lig
At these folds, do not line capsule
Bursae
anterior 1. suprapatellar
2. prepatellar
3. supf infrapatellar
4. deep infrapatellar
posterior 1. popliteal
2. semimembranosus
Nerve Supply
1. femoral n
2. obturator n
3. common peroneal n
4. tibial n
Blood Supply
1. femoral art
2. lat femoral circumflex art
3. ant tibia art
4. popliteal art
Movements
flexion
• limited by contact of back of leg with thigh
• carried out by biceps femoris, semitendinosus & semimbm
• assisted by gracilts, sartorius, popliteus
extension
• limited by ant & post cruciate & other lig
• carried out by quadriceps femoris & tensor fascia lata
med rotation
• accompanies extension from flexed position
• carried out by popliteus, semimbm, semitendinosus, sartorius & gracilis
lat rotation
• accompanies flexion
• carried out by biceps femoris
Relations
Anteriory 1. prepatellar bursa
2. tendinous expansions from vastus medialis & lateralis
Posteriorly 1. popliteal vsls
2. tibial & common peroneal n
3. lymph nodes
4. muscles forming boundary of popliteal fossa
semimbm, semitendinosus, biceps femoris,
2 heads of gastrocnemius & plantaris
Medially 1. sartorius
2. gracilis
3. semitendinosus
Laterally biceps femoris
Stability
1. tone of muscles, esp quadriceps femoris & iliotibial tract
2. ligaments esp ant cruciate & the 2 collat lig
Clinical Notes
1. injuries to menisci (esp med) wedged btw articular surfaces
movement impossible
81
2. injuries to collat lig (esp med) & cruciate lig
3. inflammation & swelling in synovial cavity may spread into suprapatellar bursa
Ankle Joint
Type
synovial hinge jt
Articulation
1. inf ends of tibia & fibula, which form a deep socket,
articulate with trochlea of talus
2. lat malleolus of fibula with lat surface of talus
3. med malleolus of tibia with med surface of talus
Capsule
• attachments
sup borders of articular surfaces of tibia & malleolus
inf talus
• thickened at sides to prevent rocking movements
Ligaments
med (deltoid) lig • attachments
apex margins & tips of med malleolus
base = post tibiotalar part talus
= tibionavicular part navicular
= tibiocalcanean part calcaneus
• functions - attach med malleolus to talus
- strengthen ankle jt
- hold calcaneus & navicular bone to talus
lat lig • 3 parts
1. ant talofibular lig = from lat malleolus to talus
2. calcaneofibular lig = from lat malleolus to calcaneus
3. post talofibular lig = from lat malleolus to post tubercle of talus
• function: attach lat malleolus to talus & calcaneus
Synovial Membrane
• lines capsule
• projects superiorly btw tibia & fibula for short distance
Nerve Supply
1. tibial n
2. deep peroneal
Blood Supply
malleolar branch of 1) peroneal art
2) ant & post tibial art
Movements
movements limited by produced by
dorsiflexion 1. tension of tendo calcaneus 1. tibialis ant
2. post fibres of med lig 2. extensor hallucis longus
3. calcaneofibular lig 3. extensor digitorum longus
4. peroneus tertius
plantar flexion 1. tension of opposing muscles 1. gastrocnemius
2. ant fibres of med lig 2. soleus
3. ant talofibular lig 3. plantaris
4. peroneus longus & brevis
5. tibialis post
6. flexor digitorum longus
7. flexor hallucis longus
Relations
Anteriorly 1. tibialis ant
(med to lat) 2. ext hallucis longus
3. ant tibial vsls
4. deep peroneal n
(ant tibial n)
5. ext digitorum longus
6. peroneus tertius
Posteriorly 1. tendocalcaneus
2. plantaris
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Postero-laterally 1. peroneus longus
(bhd lat malleolus) 2. peroneus brevis
Postero-medially 1. tibialis post
(bhd med malleolus) 2. flexor digitorum longus
3. post tibial vsls
4. tibial n
5. flexor hallucis longus
Stability
• strong during dorsiflexion - supported by strong lig
- crossed by tendons
- talus fills socket btw med & lat malleoli
• weak during plantar flexion because the ligs are less taut
Clinical Notes
1. sprains: caused by excessive inversion of foot
ant talofibular & calcaneofibular lig partially torn
2. fracture dislocations: caused by forced ext rotation & over-eversion
tip of med malleolus may be pulled off due to tightening of med hg
Femoral Triangle
It is a triangular depressed area situated in upper part of med aspect of thigh, just below inguinal lig
Boundaries
base ing lig
med border med border of adductor longus
lat border med border of sartorius
apex meeting of med border of adductor longus & sartorius
floor med = adductor longus & pectineus
lat = iliopsoas
roof skin & fascia
Contents
From lat to med
1. femoral n & its terminal branches, one of which is the saphenous n
2. femoral art which gives rise to
3. profunda femoris art which runs medially & gives rise to med & lat circumflex femoral art
4. femoral vein which crosses the art posteriorly from lat to med
5. deep ing lymph nodes
Other structures also fd are
6. lat femoral cutaneous n
7. femoral branch of genitofemoral n
Clinical Notes
1. withdrawal of bld from femoral art
arterial pulse can be taken
2. venipuncture of femoral vein
Popliteal Fossa
It is a diamond-shaped fossa located bhd the knee jt
Boundaries
superolat lower (med) border of biceps
superomed lat border of semitendinosus, semimbm & adductor magnus
inferolat lat head of gastrocnemius & plantaris
inferomed med head of gastroenemius
floor upper part formed by post surface of lower 1/3 of femur
lower part formed by capsule of knee jt & popliteus muscle
roof formed by deep fascia (popliteal fascia), fat, supf fascia& skin
Contents in Fossa
1. popliteal art
2. popliteal vein
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3. tibial n
4. common peroneal n situated just beneath biceps femoris
5. popliteal lymph nodes
In upper portion, the art is most med, then the vein & then the tibial n most lat
Inferiorly there is a rotation in vertical axis the tibial n is most supf
Clinical Notes
1. the popliteal art is prone to aneurysms
2. if popliteal art is occluded at hiatus of adductor magnus gangrene of lower leg can occur
Femoral Artery
Origin
continuation of ext iliac art at ing lig
Course
• enter thigh by passing under ing lig midway
btw ant sup iliac spine & symphysis pubis
ie at mid-inguinal pt
• descends through femoral triangle & adductor canal
• reaches adductor tubercle of temur
• ends at opening of adductor magnus
• enters popliteal space & continues as popliteal artery
Note: in femoral triangle, the artery is supf
Relations
Anteriorly upper part (in femoral triangle): skin & fascia
lower part (in adductor canal):1. sartorius
2. ant wall of femoral sheath
3. med cutaneous n of thigh
4. saphenous n crosses from lat to med
Posteriorly 1. psoas major
2. pectineus
3. adductor longus
4. femoral vein (in lower part of its course)
5. adductor magnus
Medially femoral vein
Laterally femoral n & branches
Branches
supf circumflex iliac passes through saphenous opening
area around ant sup iliac spine
supf epigastric passes through saphenous opening
umb region supply skin of ant abd wall
supf ext pudendal passes through saphenous opening
pubic tubercle supply skin of scrotum / labia majora
deep ext pudendal passes medially supply skin of scrotum / labia majora
profunda femoris
• arise from lat side abt 4 cm below ing hg
• gives off med & lat circumflex femoral art
• enters med compartment of thigh bhd adductor longus
• gives off 3 perforating art & ends as 4th perforating art
descending genicular arises near its termination
supplies knee jt
Surface Marking
• thigh in flexion, abduction & lat rotation
• knee in flexion
• draw line btw midinguinal pt & adductor tubercle
• the artery is the first 3/4 of the line
Clinical Notes
1. arterial pulse
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2. withdraw bld
3. catheterisation: pass dye into bld so as to take X-rays or angiograms
Sciatic Nerve
It is the thickest nerve in the body
Origin
• largest branch of sacral plexus in the pelvis
• L4, 5, S1, 2, 3
• consists of 2 parts 1) tibial part
2) common peroneal part
Course
• enters gluteal region through greater sciatic foramen below piriformis
• runs downwards & laterally
• enters back of the thigh at lower border of gluteus maximus
• runs vertically downwards in the midline to sup angle of popliteal fossa
• terminates by dividing into tibial & common peroneal nerves
Relations
• In the qluteal region,
supf (post) 1. gluteus maximus
2. post cutaneous n of thigh
deep (ant) 1. body of ischium
2. obturator internus & gemellus
3. quadratus femoris
4. capsule of hip jt
medial inf gluteal n & vsls
• In the thigh
supf (post) long head of biceps femoris
deep (ant) adductor magnus
medial 1. post cutaneous n of thigh
2. semitendinosus
3. semimembranosus
lateral biceps femoris
Branches
1. articular branches to hip jt
2. muscular branches
(1) tibial part to a) semitendinosus & semimembranosus
b) long head of biceps femoris
c) hamstring part of adductor magnus
(2) common peroneal part to short head of biceps femoris
3. terminal branches - tibial n
- common peroneal n
Clinical Notes
1. It is often injured by badly-placed intramuscular injections in gluteal region
2. post dislocation of hip jt, penetrating wound or fracture of the pelvis can all result in injury to the nerve
3. compression & irritation of one of the nerve roots usu results in pain along the areas of distribution of the nerve
sciatica
4. effects of lesion
- paralysis of hamstring muscles
- paralysis of all muscles below the knee, leading to footdrop
- loss of sensation below the knee except for narrow area
down med side of leg & med border of foot
which is supplied by saphenous n (femoral n)
Tibial Nerve
Origin
• terminal branch of sciatic n
• arises in lower 1/3 of thigh in most cases
• L4, 5, S1, 2 & 3
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Course & Relations
• runs downwards through popliteal fossa
• crosses bhd popliteal artery from lat to med
• sep from artery by popliteal vein
• nerve enters post compartment of leg by passing deep to
2 heads of gastrocneniius & soleus muscle
• lies on post surface of tibialis post
then on post surface of tibia
• crosses post tibial artery from med to lat
• passes bhd med malleolus, btw
tendons of flexor digitorum longus & flexor hallucis longus
• passes under flexor retinaculum
• divides into med & lat plantar n
Branches
• In the popliteal fossa
1 cutaneous sural n to 1) lat & post part of leg
2) lat border of foot
2 muscular both heads of 1) gastrocnemius
2) plantaris
3) soleus
4) popliteus
3 articular branches knee jt
• In the leg (post compartment)
1 cutaneous med calcaneal branch
2 muscular 1) soleus
2) flexor digitorum longus
3) flexor hallucis longus
4) tibialis post
3 articular ankle jt
4 terminal branches 1) med plantar n
2) lat plantar n
Surface Marking
Pt 1: apex of popliteal fossa
Pt 2: midline at level of neck of fibula
Pt 3: midway btw med malleolus & tendo calcaneus
Join all 3 points
Clinical Notes
Lesion results in
1. paralysis of all the muscles in post compartment of leg
2. paralysis of all muscles in sole of foot
3. opposing muscles dorsiflex foot at ankle jt & evert foot at subtalar jt
calcaneovalgus
4. loss of sensation from sole of foot
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2. deep peroneal n
Branches
cutaneous 1. sural communicating n joins sural n
2. lat cutaneous n of calf supplies skin on lat side of back of leg
muscular short head of biceps femoris
articular knee jt
Terminal Branches
Terminal Branches Supply
supf peroneal n 1. muscles of lat compartment of leg
ie. peroneus longus & brevis
2. lower part of front of leg & dorsum of foot
deep peroneal n 1. muscles of ant compartment of leg
ie tibialis ant, extensor digitorum longus & brevis,
extensor hallucis longus & peroneus tertius
2. ankle jt
Surface Marking
Pt 1: apex of popliteal fossa
Pt 2: back of neck of fibula
Join the 2 pts
Clinical Notes
• Lesions at neck of fibular caused by 1.fractune of neck of fibula
2. pressure from plaster casts / splints
• Effects of Lesion
Motor Effects 1. paralysis of muscles of ant compartment (supplied by deep peroneal n)
ie tibialis ant
extensor digitorum longus & brevis
peroneus tertius
extensor hallucis longus
2. Paralysis of muscles of lat compartment (supplied by supf peroneal n)
ie. peroneus longus & brevis
3. as a result of action by the opposing muscles, the foot becomes
a) plantar-flexed at ankle jt (foot-drop)
b) inverted at subtalar & tnvs tarsal jts
Sensory Effects
• loss of sensation : down ant & lat sides of leg
: on dorsum of foot & toes
: on med side of big toe
• unaffected : lat border of foot & lat side of little toe
: border of foot up to big toe
supplied by saphenous n
Popliteal Artery
Origin
continuation of femoral art as it passes through opening in adductor magnus muscle
Course
• from its origin it runs downwards & slightly laterally in popliteal fossa
• passes through intercondylar fossa
• reaches lower border of popliteus
• terminates by dividing into ant & post tibial arteries
Relations
anteriorly 1. popliteal surface of femur
2. oblique popliteal lig of knee jt
3. popliteus
posteriorly 1. popliteal vein – cross from lat to med
2. tibial n – cross from lat to med
3. above = semimembranosus
4. below = gastrocnemius & plantaris
laterally Above are
1. biceps femoris
2. popliteal vein
3. tibial n
4. lat condyle of femur
Below are
5. plantaris
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6. lat head of gastrocnemius
medially Above are
1. semimembranosus
2. med condyle of femur
Below are
3. tibial vein
4. tibial n
5. med head of gastrocnemius
Branches
cutaneous supplies 1. skin over popliteal fossa
2. back of upper part of leg
muscular supplies 1. hamstring muscles
2. gastrocnemius, plantaris & soleus
articular knee jt = lat & med sup genicular
middle genicular
lat & med inf genicular
Surface Marking
Pt 1: junction of middle & lower 1/3 of thigh
2.5 cm med to midline at back of thigh
Pt 2: midline at level of knee jt
Join pts 1 & 2
Draw a line vertically from pt 2 to level of tibial tuberosity
Clinical Notes
1. recording of bld pressures of lower limb by catheterization
2. aneurysms
3. atherosclerosis
Femoral Nerve
Origin
• largest branch of lumbar plexus
• post division of ventral rami of L2, 3 & 4
Branches
From Ant 1. med cutaneous n of thigh supplies skin of med & lat aspect of thigh
Division 2. intermediate culaneous n supplies skin of med & lat aspect of thigh
3. muscular branches to
(a) sartorius
(b) pectineus
From Post
Division
1. saphenous n
• crosses femoral art from lat to med
• desc down med side of leg with great saphenous vein
• runs along med border of foot & ends in region of ball of
big toe
supplies skin of med side of leg
& med border of fool
2. muscular branches to
a. pectineus
b. quadriceps femoris
c. rectus femoris
d. vasti also supplies hip jt
also supplies knee jt
Clinical Notes
• may be injured in gunshot / stab wounds
• effects:
a. Motor - quadriceps femoris paralysed unable to extend knee
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In walking, this is somewhat compensated for by the adductors
b. Sensory - Loss of sensation over med side of leg & med border of foot
(ie. area supplied by saphenous n)
Clinical Notes
collapse of arches flat foot
Gluteal Muscles
The gluteal muscles are: gluteus maximus, gluteus medius & gluteus minimus
Gluteus Maximus
• It is the largest musde in the body.
• It is responsible for the prominence of the buttock
Origin from 1. outer surface of ilium bhd post gluteal line
2. post surface of sacrum & coccyx
3. sacrotuberous lig
Insertion into: 1. iliotibial tract
2. gluteal tuberosity of femur
Nerve Supply inf gluteal n (L5-S2)
Actions 1. extends
2. laterally rotates
3. supports knee jt via iliotibial tract
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Gluteus Medius
Origin from 1. outer surface of ilium bounded by
2. iliac crest superiorly
3. post gluteal line posteriorly &
4. middle gluteal line inferiory
Insertion into lat surface of greater trochanter of femur
Nerve Supply sup gluteal n (L4-S2)
Actions 1. abducts
2. medially rotates
3. supporls pelvis during walking & running
ie. prevents pelvis from dipping downwards on opposite side
Gluteus Minimus
Origin from outer surface of ilium btw middle & inf gluteal lines
Insertion into ant surface of greater trochanter
Nerve Supply sup gluteal n (L4-S2)
Actions 1. abducts
2. medially rotates
3. supports pelvis during movement
Clinical Notes
• Gluteaus maximus
- intramuscular injections
given in upper outer quadrant of buttock
• Paralysis of gluteus medius & minimus
- result: raise foot on normal side
pelvis falls towards that side
- thus when walking = waddling gait (gluteal gait)
= pelvis falls towards normal side
• Trendelenberg test - stand upright
- lift up one leg
If pelvis dips, gluteus on oppo side damaged
A. Gluteal Region
Upper med quadrant Upper lat quadrant Lower med quadrant Lower lat quadrant
post rami of 1. lat br of iliohypog (L1) gluteal & perineal br fr post lat cut n of thigh
1. upper 3 lumbar (L1, 2, 2. subcostal n (T12 ant cut n of thigh (L2, 3 ant rami)
3) n rami) (S1, 2, 3 ant rami)
2. upper 3 sacral (S1, 2,
3) n
B. Thigh Region
1. Ant Aspect of Thigh
Femoral br of genitofemoral n (L1, 2)
• enters thigh bhd middle of ing hg
• thus supply
1. a small area of skin just below ing ing anteriorly
2. skin of femoral triangle
Intermediate cut n of thigh (L2, 3)
• br of femoral n
• supply ant aspect of thigh
2. Medial Aspect of Thigh
1. Ilioinguinal n
(L1)
• enters thru supf ing ring
• small skin area below med part of ing lig
2. Obturator n variable area of skin on med aspect of thigh
(L2, 3, 4 post rami)
3. Med cut n of thigh
(L2, 3 ant rami)
• br of femoral n
• supplies med aspect of thigh,
joins patellar plexus
3. Lat & Post Aspect of Thigh
Lat Aspect Post Aspect
Lat cut n of thigh (L2, 3 ant rami) Post cut n of thigh (S1, 2, 3; br of sacral pl)
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• enter bhd lat end of ing lig • enters thru lesser sciatic foramen below piriformis
• supplies skin of lat aspect of thigh & knee • supplies back of thigh & upper part of leg & skin over
popliteal fossa
C. Leg Region
1. Ant & Lat Aspect of Leg
1. Br of lat cut n of calf
(L5, S1, 2)
• br of common peroneal
• skin on upper art of ant lat surface of leg
2. Supf peroneal n
(L4, 5, S1)
• br of common peroneal
• skin on lower part of ant lat surface of leg
2. Med Aspect of Leg
• Saphenous n (L3,4)
- br of femoral n
- skin on ant med surface of leg
3. Post Aspect of Leg
1. lat cut n of calf lat side of post aspect of leg
2. br of saphenous n med side of post aspect in upper part of leg
3. sural / peroneal communicating br br of common peroneal
4. sural n supplies post aspect of lower part of leg
(L5, S1 ,2)
D. Foot
1. Plantar Aspect (Side)
1. med calcaneal br br of tibial n
med side of heel
2. med plantar n med 2/3 of sole
med 3 1/2 toes
3. lat plantar n (supf br) lat 1/3 of sole
lat 1 1/2 toes
2. Dorsal Aspect
1. Supf peroneal n
• divides into med & lat br
• med br: med side of big toe
adj sides of 2nd & 3rd toes
lat br: adj sides of 3rd to 5th toes
2. Saphenous n
• passes in front of med malleolus
• supplies skin on med side till head of 1st MT
3. Sural n supplies skin along lat side & little toe
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